PRN psychotropic orders were not limited to 14 days for two residents. One resident with Alzheimer’s disease and anxiety and another resident with dementia, depression, and anxiety both had PRN lorazepam orders that remained active without stop dates, and the DON stated there was no documentation supporting continued use beyond 14 days. The ADM and DON said staff were responsible for ensuring the 14-day limit was met, but the orders remained in place without the required documentation.
A resident with Alzheimer’s disease, psychotic disorder with hallucinations, Parkinson’s disease, and major depression was receiving mirtazapine via PEG tube, but the facility did not complete a GDR review for the psychotropic medication. The DON stated the resident was not on psych services and could not find a GDR, while the RDHS and DON reported pharmacy had reviewed the medication with no changes recommended but no physician review had been completed. The facility policy required GDRs and behavioral interventions unless clinically contraindicated, including attempts in two separate quarters within the first year after admission or medication initiation.
The facility failed to ensure psychotropic meds were reviewed for GDRs and that PRN psychotropic orders were limited to 14 days unless a rationale was documented. A resident with COPD had a PRN Ativan order extended beyond the limit without rationale, while other residents with schizophrenia, schizoaffective disorder, dementia, and anxiety had pharmacist-recommended dose reductions for meds such as buspirone, Ambien, Seroquel, and lorazepam that were not supported with documented clinical rationale. Staff, including the DON and ADM, acknowledged the missing rationales and the need for proper review of these orders.
Failure to Complete GDRs for Psychotropic Medications: Three residents receiving psychotropic drugs had no attempted GDRs in the past 12 months, except for one medication for one resident that had a single GDR since admission. One resident with PTSD, depression, and anxiety was receiving quetiapine and trazodone; another resident with major depression and severe cognitive impairment was receiving sertraline; and a third resident with bipolar disorder, anxiety, and depression was receiving paroxetine, bupropion XL, and buspirone. The DON and ADON stated no GDRs had been completed, and the LPH said she was unaware the residents were supposed to have GDRs.
A resident with Alzheimer's disease and depression received Seroquel for sleep/night terrors, but the consent for antipsychotic use listed Alzheimer's as the psychiatric condition or maladaptive behavior. Staff interviews showed the RN, DON, Administrator, and NP all recognized the diagnosis should reflect the reason for the medication, and the DON stated Alzheimer's was not an appropriate diagnosis for Seroquel.
A resident with anxiety received a PRN lorazepam order for 60 days without a documented prescriber rationale for extending the psychotropic beyond 14 days, and another resident with depression had duloxetine reviewed twice for GDR but the record lacked an appropriate rationale for not reducing the dose. The DON and ADON acknowledged the missing documentation, while the facility policy required PRN psychotropics to be limited to 14 days unless justified and required GDR attempts unless clinically contraindicated.
Two residents had psychotropic and related medications ordered and administered without the required documentation. One resident with severe dementia was receiving quetiapine, buspirone, paroxetine, Depakote ER, and donepezil, but the chart lacked current active consent for several of the drugs, had no consent for donepezil, and did not show active anxiety, depression, or psychotic disorder diagnoses to match the regimen. Another resident admitted after a hip fracture had trazodone for insomnia and quetiapine for depression despite no documented insomnia or depression diagnosis. The DON, ADM, NP, and MD all acknowledged gaps in consent and order accuracy.
A resident with dementia and severe cognitive impairment received 13 doses of topical Ativan despite no active order for that medication. The resident had an active PRN order for oral Ativan, but the topical form had been discontinued and remained on the med cart, where it was still administered. The PNP and pharmacist both confirmed there was no current order for the topical medication.
Unnecessary psychotropic medication use and missing PRN stop date: A resident had a PRN lorazepam order for anxiety with no stop date listed, despite the facility policy requiring PRN psychotropics ordered for 14 days to have a stop date and physician review for continued need. Another resident with dementia received daily Zyprexa for months even though the MDS showed no behaviors, behavior monitoring documented 0 episodes, and staff noted no dangerous behaviors or documented nonpharmacological interventions supporting ongoing antipsychotic use.
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.
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