A resident with moderate dementia and severe cognitive impairment, but no documented psychosis or behavioral symptoms, was started on Zyprexa (olanzapine) 10 mg at bedtime after a mental health NP changed her medication regimen. Physician orders listed varying indications for the antipsychotic, including depression, unspecified psychosis, anxiety, and bipolar disorder, despite the clinical record and MDS lacking corresponding documented diagnoses at the time. Nursing staff reported that they were responsible for entering and clarifying antipsychotic orders and recognized that inappropriate indications for dementia residents could constitute a chemical restraint. The DON could not locate documentation supporting a stated history of schizophrenia, and the facility’s own psychotropic drug policy required a specific, diagnosed, and documented condition for such medications, leading surveyors to find that the antipsychotic was used without an adequate indication.
Two residents received PRN Lorazepam orders without the required 14-day stop date, and the record did not show a documented diagnosed specific condition supporting PRN psychotropic use. One resident had dementia, moderate cognitive impairment, and hospice care with Lorazepam administered on multiple occasions, while the other had dementia with severe cognitive impairment and hospice care with a long-standing PRN Lorazepam order for anxiety and restlessness. The DON and ADM acknowledged PRN psychotropics required review for stop dates, and the facility policy stated PRN psychotropic use must be tied to a documented specific diagnosis and limited to 14 days.
A resident with anxiety disorder, paraplegia, and Alzheimer’s disease was receiving trazodone for insomnia, but the facility did not show that a GDR was considered or attempted after the medication was started. The care plan noted the need to review the antidepressant and consider tapering, yet progress notes did not document a GDR review, and a doctor recommendation asking for a trial dose reduction had no documented provider response. The NP said the review was denied because the resident did not want medication changes, while the DON stated GDRs were supposed to be considered every 90 days.
A resident with severe cognitive impairment and multiple psychiatric diagnoses had a PRN order for ABH gel (Ativan/Benadryl/Haldol) written to be applied transdermally every 8 hours as needed for anxiety, agitation, or restlessness, but the order lacked a required 14-day stop date. The DON acknowledged that ABH gel is a psychotropic medication and that PRN psychotropic orders should not exceed 14 days, and facility policy required Medical Records to verify that physician orders are complete and accurate. This failure to time-limit the PRN psychotropic order resulted in a cited deficiency.
A resident with Alzheimer’s disease, vascular dementia, and prior stroke was given Quetiapine (Seroquel) at bedtime, with the dose later increased, under an order written for “vascular dementia with agitation.” The MAR confirmed administration of the antipsychotic as ordered. The Interim DON and CCN acknowledged that this diagnosis was not appropriate to justify Quetiapine use and that it could cause oversedation in elderly residents. Facility policy limited antipsychotic use to specific psychiatric diagnoses such as schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, and psychosis, generally in the absence of dementia, and required use at the lowest effective dose for the shortest duration. The resident’s treatment did not conform to these policy criteria, resulting in a failure to ensure freedom from unnecessary chemical restraint.
A resident with a history of stroke-related hemiplegia, type 2 DM, and lack of coordination, and who was moderately cognitively impaired and required moderate ADL assistance, received Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before an informed consent for psychoactive medication was signed by the resident’s legal representative, and when the consent was later completed it indicated that the representative did not consent to the Trazodone. During interview, the DON stated that medications were not supposed to be given without a consent form, and facility policy required review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
The facility failed to limit PRN lorazepam orders for two residents to 14 days and to ensure required practitioner review before renewal. One resident with anxiety disorder and a stroke history had an indefinite PRN lorazepam order that was administered several times, and another resident with Alzheimer’s disease and anxiety had a PRN lorazepam order without a duration listed. Nursing leadership confirmed the orders should have had end dates and that the facility policy required documentation and evaluation for extended PRN psychotropic use.
Surveyors found that two residents with dementia-related diagnoses were routinely given antipsychotic medications (including Lurasidone, Haldol Decanoate, and Seroquel) based on orders citing unspecified psychosis, without adequate indication documented in the clinical record. Care plans and MARs showed ongoing use of these psychotropics with black box warnings, while the facility’s own policy required that such drugs be used only for clearly diagnosed and documented conditions and not as chemical restraints. In interviews, a MHNP defended broad antipsychotic use in dementia, an LVN acknowledged limited understanding of appropriate indications and reliance on provider orders and consents, and the DON confirmed that psychosis is not an appropriate indication for antipsychotics in residents with Alzheimer’s or dementia but stated staff still administered medications even when indications were inappropriate.
Failure to attempt a GDR for a resident receiving Quetiapine for depression. The resident had severe cognitive impairment, dementia, aphasia, dysphagia, and weakness, and records showed ongoing antipsychotic use without any documented GDR or clinical contraindication. A consultant pharmacist recommended a trial dose reduction, but the physician response was left blank and staff interviews showed the recommendation was not addressed.
A resident with severe dementia, anxiety, major depressive disorder without psychotic features, and insomnia received Seroquel 200 mg at bedtime as an antipsychotic without an adequate documented indication. The MDS showed severe cognitive impairment but no psychosis, while the care plan and consent listed multiple psychiatric diagnoses, and orders tied Seroquel to dementia with agitation and anxiety. The MAR confirmed administration over several days, and antipsychotic side effect monitoring was ordered. In interviews, the DON acknowledged that antipsychotics like Seroquel are not indicated for dementia and could not explain the associated risks, while a PA emphasized cautious use in the elderly. The facility’s psychotropic medication policy required appropriate use and monitoring, but surveyors determined that the indication for Seroquel use did not meet these standards.
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