A resident with anxiety disorder, insomnia, and Alzheimer's was ordered trazodone HCl 100 mg at bedtime for insomnia, but review of the MAR and TAR showed that hours of sleep were not monitored. The DON confirmed that trazodone required monitoring for antidepressant use and sleep hours when used for insomnia, and stated that the resident was not being monitored for hours of sleep.
Two residents receiving antidepressants did not have documented GDR attempts in separate quarters, and no clinical contraindications were found in the record. One resident was on Auvelity for major depressive disorder, and another was on paroxetine for depression, GAD, and insomnia; the DON stated psychotropic reviews occurred, but the chart lacked evidence of GDR attempts or contraindication documentation.
Failure to document GDR for an antidepressant: A resident with major depressive disorder received DULoxetine HCl for depression and later phantom leg pain, but surveyors found no evidence of GDRs in two separate quarters with at least one month between attempts unless clinically contraindicated. An ADON said he remembered a GDR attempt but could not locate the documentation and explained that reductions would depend on the medication’s use.
Inadequate Monitoring of Trazodone for Sleep: A resident with obstructive sleep apnea, anxiety, and insomnia received trazodone for sleep/anxiety, but the TAR did not document hours of sleep on two shifts after the order for sleep monitoring was entered. The DON stated trazodone required monitoring for adverse side effects and sleep hours, and that the missed documentation was overlooked during her record checks.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
A resident with paraplegia, PTSD, depression, anxiety disorder, and insomnia had a PRN Trazodone order for insomnia that continued beyond the 14-day limit without a documented physician rationale or duration in the medical record. The MAR showed repeated administrations of the PRN medication, including two doses within one 24-hour period, and the DON stated the psychotropic review noted GDR was contraindicated but did not document a rationale for the ongoing PRN order.
Psychotropic meds were not properly supported or monitored for several residents. Records showed Seroquel, Haldol, clonazepam, hydroxyzine, sertraline, and trazodone being used without adequate indication, behavior tracking, non-pharm interventions, ASE monitoring, or documented GDRs/psychotropic reviews. One resident had PRN antipsychotic use without the required physician evaluation, and another had an open-ended PRN order that exceeded the 14-day limit without a documented rationale.
PRN psychotropic order not limited to 14 days: A resident with insomnia, depression, and anxiety had trazodone ordered PRN for insomnia with an indefinite end date, and the record did not show a documented rationale for extending the PRN order beyond the 14-day limit. The DON stated the resident had previously had a 14-day stop date, the order was reactivated after a hospital stay, and the resident had only taken one dose while averaging 8 to 9 hours of sleep per day.
Failure to Attempt GDR for Psychotropic Medications: The DON and record review showed that several residents receiving psychotropic meds, including antianxiety, antidepressant, mood stabilizer, and sleep medications, did not have documented GDR attempts or contraindication rationale. Behavior monitoring and MAR review showed little or no current target behaviors for the residents reviewed, yet the chart lacked evidence of GDRs for meds such as Ativan, duloxetine, Lamictal, trazodone, valproic acid, and temazepam.
The facility failed to ensure psychotropic medications were free from unnecessary use because monitoring was not documented for behaviors, ASE, and non-pharmacological interventions for three residents. One resident receiving trazodone for insomnia had no documented ASE or non-pharmacological monitoring, another resident receiving buspirone and sertraline had no documented monitoring despite behaviors including refusal of care, aggression, and delusions, and a third resident receiving venlafaxine and clonazepam had no documented monitoring for side effects or behaviors. The DON acknowledged that monitoring for anti-depressants, anti-anxiety medications, and hypnotics was not documented.
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