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.
Unnecessary AP use without documented behaviors. A resident with cognitive impairment, depression, and non-Alzheimer’s dementia received Seroquel 12.5 mg nightly even though the MDS showed no behaviors, delirium, or rejection of care. The chart listed dementia without behavioral, psychotic, mood, or anxiety disturbance as the indication, while the AP care plan referenced behavior management and target behaviors such as agitation, anxiety, delusions, and hitting/kicking. Target behavior documentation showed no behaviors, and the SS Director stated dementia was not an appropriate indication for AP use and the medication should have been evaluated and/or discontinued.
Failure to document a resident-specific rationale for declining a psychotropic GDR. A resident with cognitive impairment, anxiety, depression, and insomnia had long-term citalopram use and lorazepam for anxiety-related behaviors. Pharmacy recommended a citalopram GDR, but the provider left the required rationale blank, and the IDT note cited maladaptive behaviors without identifying them or linking them to citalopram. The record also did not show a failed GDR of citalopram.
Psychotropic medication monitoring and documentation were deficient for three residents. A resident with anxiety received clonazepam without documented ASE monitoring, a cognitively impaired resident received PRN Seroquel without an AIMS test and PRN lorazepam without a 14-day stop date, and another resident with anxiety received repeated higher-dose PRN lorazepam without documentation of the behaviors supporting the dose given. Staff acknowledged missing monitoring and documentation in the records.
Unnecessary Antipsychotic Use for Resident with Dementia and Behaviors: A resident with dementia, depression, and severe cognitive impairment was given Seroquel for behaviors including yelling, screaming, hitting, grabbing, and increased confusion. The record lacked information about pre-admission behaviors and did not include personalized monitoring for psychosis, while staff noted the resident came from an ALF, believed they worked at the facility, and had also been found to have a UTI.
Psychotropic meds were not regularly monitored or documented with specific target behaviors for several residents. Records showed generic behavior monitors, care plans that did not link meds to the behaviors they were intended to treat, missing documentation of non-pharmacological interventions before PRN alprazolam, and inconsistent nursing/CNA charting for residents receiving antipsychotic and antidepressant medications.
Failure to monitor psychotropic medication side effects and behaviors for three residents. One resident on trazodone had no documented monitoring for adverse effects or behaviors, another resident on quetiapine had no documented orthostatic BP checks despite an order for them, and a third resident on citalopram and buspirone had no documented side effect or behavior monitoring. The DON stated the monitoring should have been done, and staff noted the behavior monitoring was missing.
Psychotropic meds were not properly monitored or justified for three residents. One resident with dementia and depression had quetiapine and trazodone ordered, but there was no target behavior monitoring for the antidepressant. Another resident had escitalopram and PRN lorazepam for anxiety despite no MH dx listed in the facility record, and the DNS said the diagnosis and justification should have been documented. A third resident with Alzheimer’s, anxiety, and physical aggression received PRN risperidone, lorazepam, and haloperidol for agitation or care-related behaviors, but the TARs did not document the behaviors or non-drug interventions attempted before the meds were given, and the resident also showed oral-facial movements consistent with tardive dyskinesia that were not documented on the TAR.
Unnecessary psychotropic medication use was identified for two residents. One resident with dementia, stroke history, and agitation was given Seroquel for dementia with agitation despite no clear psychosis diagnosis, and staff relied on the provider rather than consistently reviewing behavioral health notes. Another resident with dementia, depression, and behavioral disturbance received daily Seroquel for dementia with agitation even though PASRR, MDS, progress notes, and psychoactive reviews did not document psychosis; the resident also slept much of the day and staff reported no hallucinations or delusions.
PRN psychotropic meds were not properly limited to 14 days or supported by documented rationale for extended use, and non-pharmacological interventions were not consistently documented for two residents. One resident had PRN Prochlorperazine ordered for nausea/vomiting with no timely non-pharm documentation and repeated administrations, while another resident had PRN Ativan ordered without an end date and used over several months for comfort, agitation, sleep, and other symptoms without the required justification.
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