A resident with depression and delusional disorders was prescribed Olanzapine for delusions, but the MAR and care plan showed no targeted behavior monitoring or other behavioral documentation to support the medication’s use or effectiveness. The SS Director and DNS both confirmed the resident was not on behavior monitoring, despite the facility stating residents on antipsychotics were placed on it.
A resident with anxiety disorder, heart failure, and hospice services received psychotropic PRN lorazepam without the ordered first use of albuterol on multiple occasions. Staff interviews showed the CNA associated the resident's hallucinations with anxiety, the CMA relied on nurses for assessment before PRN use and gave lorazepam without being told to give albuterol first, and the DNS said the order was unclear and staff should follow physician orders as written.
PRN Psychotropic Medication Not Discontinued as Required: A resident with dementia and a maxillofacial fracture had a PRN Lorazepam order that remained active beyond the facility’s 14-day limit for new PRN psychoactive meds. The MAR showed the medication was last administered once, and the pharmacist flagged the order for discontinuation or time-limited extension with written justification, but staff did not obtain a physician response and later confirmed the order should have had a 14-day stop date.
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.
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