Failure to ensure appropriate use of an antipsychotic medication for a resident with dementia and depression. The resident was prescribed Risperidone for dementia with behaviors, but the record had no target-behavior monitoring order and no documentation of admission review for the psychotropic. An LPN, the Social Services Director, and the DON stated the diagnosis was not appropriate for Risperidone and that the resident should have had related behaviors monitored.
A resident with dementia and severe cognitive impairment was receiving Quetiapine for behavioral symptoms, but the facility did not complete the required AIMS monitoring at the expected interval. The record showed the AIMS was done on admission and then not again until about 10 months later, despite staff stating it should be completed on admission and every 6 months for residents on antipsychotics.
A resident with dementia, UTI, diabetes, and acute pyelonephritis was prescribed and given Seroquel for agitation even though the record did not document behaviors or agitation. The EHR and MDS showed no indication for antipsychotic use, and staff stated the order did not meet expectations.
A facility failed to ensure several residents were free from unnecessary psychotropic meds. Records showed antipsychotics and other psychotropics were used without adequate documentation of indication, monitoring, GDRs, or timely consent. For some residents, MDSs showed no hallucinations, delusions, or behaviors to match the medication orders, while staff acknowledged missing behavior monitoring, incomplete psychotropic documentation, and diagnoses that did not support the meds.
A facility failed to properly document and monitor psychotropic use for multiple residents. Records showed missing AIMS testing, no 14-day reassessment for PRN antianxiety meds, and no documented side effect monitoring for antipsychotic, antidepressant, or antianxiety medications. Staff also confirmed target behaviors were vague, overlapped across meds, or were not tied to specific psychotropics, and one resident’s quetiapine GDR was not supported by the charted behaviors.
The facility failed to ensure 3 residents were free from unnecessary psychotropic medications. One resident received PRN antianxiety medication without documented target behaviors or documented non-pharmacological interventions before administration. Two other residents had antidepressant and antipsychotic orders, but MAR/TAR records did not show ASE monitoring documentation, and staff could not provide evidence that the required monitoring had been completed.
Psychotropic medication monitoring and documentation were incomplete for several residents. One resident received quetiapine without a documented indication or diagnosis, another received Seroquel without orthostatic BP monitoring, and two residents on routine antipsychotics did not have timely AIMS assessments. Staff confirmed the missing diagnosis, BP checks, and AIMS timing did not meet expectations.
A facility failed to ensure psychotropic meds were supported by clinically valid diagnoses for 3 of 5 residents reviewed. One resident with anxiety disorder and intact cognition had an antidepressant ordered for transition from acute care to LTC, another resident with anxiety disorder and depression had an antidepressant ordered for living in LTC, and a resident with Lewy body dementia, agitation, and psychosis had antianxiety and antipsychotic meds ordered for pain aggravated by ADLs and hospice care even though the DON said the resident was not on hospice and the diagnoses were incorrect.
Two residents had psychotropic medication-related deficiencies involving missing documentation and monitoring. One resident with depression and moderate cognitive impairment had a PRN lorazepam order left active beyond 14 days without a documented clinical rationale, no care plan focus on the target behaviors, and no documented NPIs before eight PRN doses were given. Another resident with severe cognitive impairment and dementia-related behavioral disturbance had a Depakote behavior-monitor order listing target behaviors and NPIs, but the TAR did not provide a place to document the behaviors or interventions.
Psychotropic Medications Given Without Required Behavior Monitoring: The facility failed to document behavior monitoring, target behaviors, and non-pharmacological interventions for multiple residents receiving routine and PRN psychotropic medications. Residents with diagnoses including anxiety, depression, PTSD, schizophrenia, dementia, Alzheimer’s disease, delirium, and Parkinson’s disease received medications such as buspirone, duloxetine, quetiapine, trazodone, escitalopram, lorazepam, hydroxyzine, and alprazolam, but the record lacked licensed nurse documentation showing behaviors were monitored or that non-pharmacological interventions were attempted and effective.
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