Failure to Implement GDR and Monitor Psychotropic Medication Use
Summary
The facility failed to perform gradual dose reductions (GDR) for psychotropic medications in two residents. Despite recommendations from the consultant pharmacist and agreement from the psychiatric nurse practitioner (NP), the facility did not implement the changes in medication dosages for these residents. This oversight resulted in the residents continuing to receive higher doses of medications than necessary, increasing the risk of adverse effects. The facility also did not limit the duration of PRN lorazepam for a resident to 14 days or document a longer duration with a clinical rationale. This failure to adhere to the recommended duration for PRN medications increased the risk of the resident receiving the medication when it was no longer clinically appropriate, potentially leading to adverse effects. Additionally, the facility did not ensure that an antipsychotic medication was used for a clear indication or diagnosed condition for another resident. The facility also failed to monitor and document target behaviors related to the use of this medication. Furthermore, the facility allowed the simultaneous use of two antidepressants without clinical justification for a resident, increasing the risk of adverse effects.
Plan Of Correction
The Director of Nursing/designee audited the physician orders for psychotropic medications of all residents to identify residents who may be potentially affected by the facility practice on 3/6/2025. Thirty-five residents with psychotherapeutic medication therapy were audited. Five of 35 residents required the licensed nurse to clarify the physician's order with resident-specific targeted behaviors, stop date, duplicate medication therapy, and monitoring of targeted behaviors. The Director of Social Services/designee audited resident records who receive psychotherapeutic medications on 3/6/2025 to identify residents who do not have documented evidence of a gradual dose reduction in the medical record. Thirty-five residents receiving psychotherapeutic medications were audited. Two of 35 residents required a gradual dose reduction. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The IDT will review and revise the care plans of all residents with psychotherapeutic medication therapy to ensure care plans include resident-specific targeted behaviors and justification for dual medication therapy when indicated on 3/6/2025. The Director of Nursing/designee will re-educate licensed nurses and the IDT on the facility policies and procedures Unnecessary Medications, including required gradual dose reduction, justification when dual medication therapy is indicated, ensuring PRN medications have a stop date, and monitoring clearly defined behaviors in the medical record on or before 3/21/2025. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify the order includes a stop date for PRN medications, diagnosis, targeted behavior(s), and targeted behavior, and provide copies of the audits to the Director of Nursing for tracking and trending analysis and further follow-through as needed. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have complete physician orders, including targeted behaviors, justification for dual medication therapy, stop dates, and clearly defined diagnosis to support the use of medication. The IDT will review the orders of residents at the onset of psychotherapeutic medication changes or admission, whichever comes first, to ensure complete physician orders including targeted behaviors, justification for dual medication therapy, stop dates, and a clearly defined diagnosis to support the use of medication. They will also identify opportunities for gradual dose reduction attempts five times weekly during the morning clinical meeting. The Director of Nursing/designee will re-educate licensed nurses and the IDT on the facility policies and procedures Unnecessary Medications, including required gradual dose reduction, justification when dual medication therapy is indicated, ensuring PRN medications have a stop date, and monitoring clearly defined behaviors in the medical record on or before 3/21/2025. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify the order includes a stop date for PRN medications, diagnosis, targeted behavior(s), and targeted behavior, and provide copies of the audits to the Director of Nursing for tracking and trending analysis and further follow-through as needed. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have complete physician orders, including targeted behaviors, justification for dual medication therapy, stop dates, and clearly defined diagnosis to support the use of medication. The IDT will review the orders of residents at the onset of psychotherapeutic medication changes or admission, whichever comes first, to ensure complete physician orders including targeted behaviors, justification for dual medication therapy, stop dates, and a clearly defined diagnosis to support the use of medication. They will also identify opportunities for gradual dose reduction attempts five times weekly during the morning clinical meeting. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development will monitor the completion of staff training during new hire orientation, and as needed, on the facility's unnecessary medication policy and procedure. The Pharmacy Consultant shall monitor the medication regimen of residents each month to identify the potential for unnecessary drug use and report the results to the Director of Nursing and QAA quarterly. The Director of Social Services will monitor the Medical Records verification of complete physician orders, track gradual dose reduction attempts, and identify opportunities for GDR, and clearly defined diagnosis for use. Variance to standard concerns identified will be reported to the Director of Nursing. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.
Penalty
A resident with dementia and behavioral disturbances received a PRN order for Lorazepam that was not limited to 14 days and lacked a documented rationale for continuation beyond this period. The medication was administered without evidence that non-pharmacological interventions were attempted first, and required documentation was missing.
A resident was administered PRN Ativan on three occasions, but documentation showed that non-pharmacological interventions were only attempted before two of those administrations. An LPN confirmed that there was no record of any intervention being tried prior to one of the doses, resulting in a deficiency related to the use of psychotropic medications.
The facility did not reassess a PRN psychotropic medication for a resident with severe cognitive impairment, allowing continued use without physician review, and also failed to complete an AIMS assessment for another resident receiving antipsychotic medication. Staff were unaware of the requirements for medication reassessment and AIMS completion.
Two residents received routine Seroquel administration without proper documentation of targeted behaviors, monitoring for adverse effects, or rationale for continued use. In both cases, there was no evidence of attempted gradual dose reduction (GDR) or clinical justification for not attempting GDR, and staff interviews confirmed these documentation gaps.
A resident admitted for hospice care with dementia and Parkinson's disease was prescribed lorazepam and quetiapine for anxiety and psychosis, but staff did not initiate monitoring for targeted behaviors or medication side effects until two days after starting the medications. Nursing staff and leadership confirmed that monitoring should have begun with the initiation of psychotropic medications, as required by facility policy.
A resident with moderate cognitive impairment was prescribed psychotropic medications, but the facility failed to complete and document required Gradual Dose Reductions (GDRs) as per regulatory standards. Only one GDR attempt was made for each medication over extended periods, and there was no supporting documentation for GDRs or contraindications. Staff were unclear on GDR requirements, and facility policy lacked specific time frames for GDR attempts.
Failure to Limit and Document PRN Psychotropic Medication Orders
Penalty
Summary
Facility staff failed to ensure compliance with regulations regarding the use of as needed (PRN) psychotropic medications for a resident with dementia and behavioral disturbances. A physician order for Lorazepam, to be administered prior to blood draws, was written as a PRN order without a 14-day limitation or a specified duration and discontinuation date. The medical record did not contain documentation from the physician providing a rationale for continuing the PRN order beyond 14 days, as required by regulation. Additionally, review of the medication administration record showed that Lorazepam was administered to the resident, but there was no documentation indicating that non-pharmacological interventions were attempted prior to giving the medication. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate documentation and understanding of the requirements for PRN psychotropic medication orders.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPI) were provided or attempted prior to administering a psychotropic medication for one resident. Specifically, a resident was prescribed Ativan (Lorazepam) on an as-needed basis and received doses on three separate occasions. Documentation confirmed that NPIs were attempted before administration on two of those dates, but there was no documentation of any NPI being attempted prior to the administration on the third date. During interviews, an LPN explained that the facility's process is to attempt NPIs before administering psychotropic medications and that such attempts should be documented either in the electronic Medication Administration Record (eMAR) or in a progress note. Upon review of the resident's records, the LPN was unable to find any documentation indicating that an NPI was attempted before the administration of Ativan on the date in question, confirming the deficiency.
Failure to Reassess PRN Psychotropic Medication and Complete AIMS Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary medications by not reassessing a PRN psychotropic medication as required. Specifically, a resident with severe cognitive impairment and diagnoses including depression and Alzheimer's Disease had a PRN order for trazodone to address restlessness and agitation. The order, initiated at admission, was not reassessed by the physician after the initial 14 days or at any subsequent time, despite ongoing use over several months. There was also no evidence that the resident was seen by behavioral health services for medication management. Facility staff, including the nurse and Director of Nursing, were unaware that the medication had not been re-evaluated as required by policy. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for another resident who was receiving antipsychotic medication. This resident, admitted with diagnoses including suicidal ideations, depression, aphasia, and chorea, had a physician's order for daily risperidone. Review of the medical record showed no documentation that an AIMS assessment was completed, as required for residents on antipsychotic medications. Staff interviews revealed a lack of awareness and training regarding the completion and timing of AIMS assessments.
Failure to Monitor and Document Antipsychotic Use and GDR for Two Residents
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by policy and regulation. For one resident with Alzheimer's disease, dementia with agitation, major depressive disorder, and anxiety, Seroquel was administered routinely without identifying or monitoring resident-specific target behaviors or signs and symptoms of potential adverse consequences. Physician's orders for Seroquel did not specify targeted behaviors or monitoring parameters, and the medical record lacked documentation of monitoring for efficacy or adverse effects. For another resident with Alzheimer's disease, depression, and anxiety, Seroquel was also administered on a routine basis. The medical record did not contain a documented rationale for the use of Seroquel, nor was there evidence that a gradual dose reduction (GDR) was attempted or that a clinical contraindication to GDR was documented by the prescriber. Although a consultant psychiatric nurse practitioner recommended against GDR due to potential psychiatric destabilization, this recommendation was not reviewed or documented by the attending physician or nurse practitioner in the resident's record. Interviews with facility staff, including the Director of Nursing and Social Worker, confirmed that there was no documentation of resident-specific targeted behaviors, monitoring for adverse consequences, or rationale for continued use of Seroquel. The Director of Nursing acknowledged that these elements should have been documented but were not completed for the residents in question.
Failure to Monitor Behaviors and Side Effects for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident who was admitted under general in-patient hospice care with diagnoses including dementia, Parkinson's disease, and uncontrolled behaviors posing a danger to self and others. Upon admission, the resident was prescribed psychotropic medications, specifically lorazepam for anxiety, restlessness, agitation, and shortness of breath, and quetiapine fumarate for psychosis and unprovoked physical behavior. However, there was no documented evidence that monitoring for targeted behaviors such as anxiety and psychosis, or for side effects related to the use of these psychotropic medications, was initiated until two days after admission. Interviews with nursing staff and facility leadership confirmed that monitoring for behaviors and side effects should have been conducted from the time the medications were started. The facility's own policy required staff to monitor for adverse side effects associated with psychotropic medication use. The lack of timely monitoring was acknowledged by the RN, ADON, LVN, and DON, all of whom stated that such monitoring was expected and should have been implemented as soon as the medications were ordered.
Failure to Complete and Document Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) was completed for one resident reviewed for unnecessary medications. The resident, who was moderately cognitively impaired, was prescribed Sertraline for depression and Zyprexa for dementia with psychotic disturbance. Documentation showed only one GDR attempt for Sertraline in over two years and only one GDR attempt for Zyprexa in the previous thirteen months. There was no supporting documentation in the electronic health record (EHR) for a GDR on the date indicated in the Minimum Data Set (MDS), nor was there documentation from the pharmacy or provider requesting a GDR or supporting contraindications for GDR. Staff interviews revealed confusion regarding the requirements for GDRs, with staff referencing facility policy and pharmacy guidelines but unable to provide documentation supporting their practices. The facility's policy did not specify time frame requirements for GDR attempts, and no further documentation was provided to support that appropriate GDRs or contraindications had been addressed for the resident's psychotropic medications.
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