Failure to complete GDR review and medication-specific psychotropic monitoring. A resident with dementia and depression remained on trazodone for insomnia without provider documentation supporting why dose reduction was not done, despite documented daytime sedation and prolonged sleep periods. Two other residents receiving multiple psychotropics had broad, nonspecific TAR behavior monitoring, and one resident’s clonazepam had no target behavior or side effect monitoring tied to that medication.
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.
Unnecessary psychotropic medication use and inadequate documentation: Two residents received psychotropic meds without proper consent, behavior monitoring, or documented non-pharmacological interventions. One resident on hospice with dementia and other diagnoses was given an ABH gel containing lorazepam, diphenhydramine, and haloperidol multiple times despite no documented attempts at non-drug interventions and incomplete behavior tracking; the other resident was maintained on Abilify for unspecified depression and pseudobulbar affect, with minimal behavior documentation and no documented non-pharmacological interventions.
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.
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