A resident with depression and insomnia received trazodone 50 mg at HS after the order was changed from insomnia to depression. An IDT psychoactive drug review recommended a GDR to reduce the dose to 25 mg and update the diagnosis, and the physician verbally agreed, but the GDR was not completed and documentation of implementation could not be found.
The facility failed to complete monthly psychoactive drug reviews for a resident with bipolar disorder who was receiving Abilify and bupropion. A psychoactive drug review noted no changes and planned reassessment the following month, but no further review was documented, and the SSD and DNS acknowledged the resident had not been reassessed since October 2025.
A resident with depression, anxiety, and hospice services received PRN lorazepam without an end date on the order, and the PRN use continued beyond 14 days without documented physician rationale. The resident’s care plan called for review of PRN anti-anxiety medication by day 14, but the MAR showed repeated use over multiple days, and staff documented ongoing anxiety and a later scheduled anxiolytic order.
A resident with bipolar disorder and PTSD was receiving buspirone 10 mg BID, and pharmacy noted the psychotropic was due for a GDR because the resident was not experiencing anxiety. The provider agreed to reduce the dose to 5 mg BID, but the order was not implemented in a timely manner, and an LPN Resident Care Manager acknowledged the delay.
Failure to document GDRs for psychotropic meds: four residents with diagnoses including schizophrenia, bipolar disorder, dementia with behavioral disturbance, and anxiety were receiving antipsychotic and other psychotropic medications as ordered, but their records showed no attempted GDRs and no physician documentation that GDRs were clinically contraindicated. The RNCM stated the residents were on an ECU and believed GDRs were not warranted due to their diagnoses, but could not provide the required documentation.
A resident admitted with dementia was started on Risperdal and olanzapine, but the AIMS baseline assessment was not completed when the antipsychotics were initiated. The AIMS was not documented until about three months after admission, and staff acknowledged it was not done timely for baseline assessment.
Failure to complete required AIMS monitoring for a resident receiving quetiapine. A resident with vascular dementia with agitation and depression was prescribed quetiapine 75 mg BID, but the record showed no AIMS assessment completed on admission. The RNCM/DNS/IP believed AIMS was not needed until 6 months after admission, while the Regional RN Consultant confirmed the resident required AIMS on admission and every 6 months while on antipsychotic medication.
A resident with insomnia and intact cognition received duplicate trazodone orders in the MAR, and staff interviews showed the extra order was entered and confirmed in error without proper verification. The resident reported being overly sleepy for two days and missing PT, and a family member said the resident was too tired to function after being told the trazodone had been increased.
Failure to document nonpharmacological interventions before PRN lorazepam use: A resident with dementia had a PRN lorazepam order for agitation, anxiety, restlessness, or nausea that was given 20 times, but the record did not show a rationale for use or evidence that nonpharmacological interventions were tried first. Staff described redirection methods such as TV, music, DVDs, hot cocoa, and care choices, and the LPN RCM acknowledged the expectation to document behaviors and use nonpharmacological interventions before giving the PRN med.
Psychotropic medication documentation was deficient for two residents. One resident received PRN lorazepam beyond the required 14-day period without a documented stop date, and another resident had lorazepam, escitalopram, and buspirone continued without documented clinical rationale for not reducing the dose or discontinuing the meds, despite a pharmacy consult noting the need for that rationale.
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