Surveyors found that the facility failed to identify and monitor target behaviors for two cognitively intact residents receiving antipsychotic medications. One resident with psychotic and mood-related diagnoses was given Abilify at bedtime for psychotic disorder with hallucinations, and another resident with Wernicke’s encephalopathy, alcohol abuse, psychotic disorder with hallucinations, and dementia was given Zyprexa at bedtime. In both cases, medical record reviews showed no documented target behaviors or behavior monitoring related to the antipsychotic use, and the ADON and DON each confirmed that staff had not established or tracked target behaviors for these medications.
Failure to monitor psychotropic medication side effects for two residents. One resident with PTSD and insomnia had orders for Ativan PRN and mirtazapine, and another resident with schizoaffective disorder and a history of TBI had orders for divalproex and mirtazapine. Both residents were cognitively intact, but their care plans did not direct monitoring for psychotropic side effects, and no active physician orders were in place for that monitoring; the DON verified the monitoring was not completed.
Failure to monitor psychotropic medication effectiveness and side effects affected three residents receiving psychotropic meds. One resident with psychosis, mood disorder, anxiety, and dementia had orders for escitalopram, olanzapine, and mirtazapine, but no documented monitoring. Another resident with dementia, hallucinations, anxiety, restlessness, and agitation received PRN clonazepam six times with no evidence of monitoring. A third resident with dementia, Lewy body neurocognitive disorder, PTSD, and depression had orders for mirtazapine and clozapine, but the record showed no monitoring for adverse reactions, EPS, tardive dyskinesia, suicidal ideation, or unusual behavior.
Failure to monitor residents on psychotropic medications. Three residents receiving psychotropic meds were not monitored for behaviors or medication side effects. One resident with bipolar disorder and anxiety received clonazepam, another resident with depression received sertraline, and a third resident with dementia and depression received aripiprazole and Lexapro. The RNCC confirmed no behavior monitoring was in place to assess efficacy and/or side effects.
Unjustified psychotropic medication use was identified for a resident receiving Olanzapine for schizophrenia despite no schizophrenia diagnosis in the record. The MDS and PASRR also did not show schizophrenia, and the DON confirmed the resident was receiving the medication without that diagnosis documented. The Administrator stated the diagnosis had been identified after a behavioral health hospital stay, but hospital paperwork confirmed there was no schizophrenia diagnosis.
A resident with dementia and intact cognition was given a one-time dose of Haldol by an LPN after an attempt to hit staff during a dressing change, despite no documented behaviors or justification in the medical record. Facility policy required antipsychotic use only for specific conditions and after other interventions, but there was no evidence of imminent danger or proper documentation to support the administration.
Two residents were administered psychotropic medications without appropriate diagnoses or proper justification for not attempting gradual dose reductions. One resident received an antipsychotic for anxiety without a documented psychiatric diagnosis, while another continued on multiple psychotropic drugs despite pharmacy recommendations for dose reduction, with provider denials lacking clear clinical contraindication.
A resident with dementia and Parkinson's disease was given Seroquel without a documented or appropriate diagnosis to support its use. The medication was ordered and administered for anxiety and hallucinations, despite the absence of documented behaviors or psychiatric disorders and without adherence to FDA-approved indications. Facility staff, including the NP and DON, confirmed the lack of proper documentation and awareness of policy requirements.
A resident with severe cognitive impairment and multiple diagnoses received PRN Ativan gel for agitation and anxiety without a required 14-day stop date. The medication was administered repeatedly over several months, contrary to facility policy and regulations, as confirmed by interviews with clinical leadership.
The facility did not ensure that prn orders for psychotropic medications, including anti-psychotics and anti-anxiety drugs, were limited to 14 days and only extended with proper face-to-face evaluations and clinical rationales. Two residents received prn medications for extended periods without required end dates or documentation of non-pharmacological interventions prior to administration, contrary to facility policy and federal regulations.
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