A resident with depression, anxiety, and moderate cognitive impairment received PRN Hydroxyzine on multiple occasions, but the record did not show that individualized non-pharmacological interventions were tried or ineffective before administration. The chart also lacked the prescriber’s clinical rationale and duration for continuing the PRN psychotropic order beyond the 14-day limit.
PRN psychotropic medication was used without the required clinical rationale for continued use beyond 14 days and without documentation of non-pharmacological interventions before administration. A resident with dementia, delusional disorder, and diabetes had a PRN Lorazepam order for anxiety, and the MAR showed the medication was given twice without evidence of prior non-medication interventions; the DON and ADON confirmed the missing stop date and lack of supporting rationale.
Failure to Attempt Non-Pharmacological Interventions Before PRN Lorazepam: A resident with neurocognitive disorder with Lewy bodies, CVA, and insomnia was cognitively impaired and had behaviors related to poor impulse control. Staff administered PRN lorazepam multiple times for agitation, but there was no documented evidence that non-pharmacological interventions were attempted first, and the ADON confirmed this in interview.
A resident received Lorazepam for anxiety and Duloxetine for depression, but the facility did not show adequate support for continued psychotropic use. The care plan called for monitoring target behaviors and depressive symptoms, yet the MAR/TAR reflected only one behavior being tracked, and the consultant pharmacist’s request to consider GDR or discontinuation was answered only with “medically stable.” The DON and NHA confirmed there was no evidence of the required behavior monitoring or other rationale supporting the ongoing regimen.
A resident with asthma, COPD, and severe cognitive impairment received PRN Lorazepam on multiple occasions for anxiety, but the record did not show that non-pharmacological interventions were tried or ineffective before administration. The chart also lacked a documented clinical rationale and duration for continuing the PRN psychotropic order beyond the 14-day limit, and the DON and NHA confirmed the missing documentation.
Failure to document PRN psychotropic review: A resident with Alzheimer's disease, dementia, and anxiety disorder received PRN Lorazepam gel for anxiety, but the MAR showed repeated use without documented physician re-evaluation of the continued need and without a stop date after 14 days. The Administrator confirmed the medication had not been re-evaluated and no stop date had been ordered.
Failure to Monitor Psychotropic Medication Effects: The facility failed to monitor behaviors and medication side effects for three residents receiving psychotropic medications. One resident received quetiapine for anxiety, another received risperidone for psychotic disorder with delusions, and a third received Seroquel with directions to monitor for sedation and increased falls; MARs and progress notes showed the required monitoring was not documented, and the DON confirmed the findings.
Failure to Monitor Antipsychotic Use: A resident received Risperidone 2 mg twice daily, but the clinical record lacked evidence of ongoing monitoring of target behavior symptoms or assessment for side effects tied to the antipsychotic. The care plan directed staff to monitor and document effectiveness and adverse reactions, and the DON confirmed the facility could not provide evidence of the required tracking.
Unnecessary Psychotropic Medications: The facility failed to keep two residents’ med regimens free from unnecessary psychotropic meds. One resident was ordered Risperdal for schizoaffective disorder without documentation that other interventions were tried to rule out an acute change in condition, and another resident with dementia, HF, and cerebral infarction was ordered Zyprexa for a new schizophrenia diagnosis without documented testing or other interventions first. The record also lacked a rationale for extended Ativan use beyond 14 days.
The facility failed to document appropriate indications before giving a resident PRN Lorazepam and did not document behavior or psychotropic side effect monitoring for a resident receiving Olanzapine. The resident had bipolar disorder and anxiety disorder, and the DON confirmed the PRN medication was given without appropriate indications and that monitoring was not done.
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