A resident with Alzheimer’s disease, severe cognitive impairment, depression, anxiety, delusions, and behavioral symptoms was receiving lorazepam both as a scheduled dose and PRN every four hours for restlessness and agitation, including a topical form if oral medication was refused. Physician orders for the PRN lorazepam lacked stop dates, and although the consultant pharmacist recommended a stop date or GDR, the physician declined, citing hospice and palliative care without specifying a duration. The nurse overseeing psychotropic use confirmed the absence of a stop date and uncertainty about requirements for palliative residents, despite facility policy mandating that PRN psychotropic medications (other than antipsychotics) be limited to 14 days unless a longer timeframe is explicitly ordered. This resulted in a deficiency related to unnecessary psychotropic medication management.
Surveyors identified that two residents with dementia, depression, and anxiety were receiving daily antipsychotic medications without documented physician rationale or risk–benefit analysis for their continued use with non-approved indications. Each resident’s MDS showed severely impaired cognition and ongoing psychotropic use, while their care plans only directed staff to administer medications as ordered. Physician orders specified olanzapine for behaviors or a psychotic disorder, but the EMRs lacked documentation of multiple unsuccessful nonpharmacological interventions and risk–benefit considerations, and the available psychoactive medication consent forms did not contain the required physician justification, contrary to facility policy on psychotropic drug use.
A resident with hypertension, DM, severely impaired cognition (BIMS 0), and dependence in most ADLs was receiving multiple psychotropic medications, including an antianxiety agent. The EMR contained an order for lorazepam cream 0.5 mg to be applied every eight hours and PRN for dementia, but the order did not include the required 14-day stop date or any specified duration, and there was no physician rationale documented for extended PRN use. Staff interviews indicated that nurses were expected to notify physicians that PRN lorazepam required a stop date and that the DON was a second check for orders, yet this did not occur, and the facility was unable to provide its unnecessary psychotropic drug policy when requested.
A resident with Alzheimer’s disease, prior stroke, insomnia, and major depressive disorder was maintained on Quetiapine for “unspecified dementia with psychotic disturbances” without a CMS-approved indication and without behavioral monitoring. The MDS showed severe cognitive impairment but no documented behaviors, and the care plan referenced resisting care and yelling out but did not include a clear psychiatric indication for antipsychotic use. The resident was observed calm and behavior-free, while the EMR lacked behavior tracking tied to the antipsychotic. A consultant pharmacist recommended gradual dose reduction, which the provider declined, and staff acknowledged that antipsychotics are not indicated for dementia alone and that the resident’s representative refused medication changes, leaving the facility unable to document an appropriate rationale consistent with its own psychotropic medication policy.
Surveyors found that the facility did not ensure appropriate indications and documentation for psychotropic medications. A resident with dementia, depression, Parkinson’s disease, and encephalopathy received an antipsychotic for dementia with agitation without a documented physician rationale, nonpharmacological interventions, or risk–benefit analysis as required by facility policy. Two other residents with dementia, depression, and anxiety had PRN antianxiety medications ordered without 14-day stop dates or specified durations, and their records lacked the required physician rationale for extended PRN use, despite staff acknowledging that such orders should include a 14-day limit and reassessment.
A resident with anxiety, dementia, and major depressive disorder received PRN Ativan cream for agitation without a 14-day stop date or documented physician rationale for ongoing use. Staff administered the medication in response to agitation, but the order and medical record lacked required documentation, contrary to facility policy.
A resident with dementia and severely impaired cognition was administered antipsychotic medications without appropriate physician documentation, including rationale, evidence of unsuccessful nonpharmacological interventions, or risk-benefit assessment. The facility's records included an unsigned consent form and lacked the required supporting documentation, despite policy requirements for such oversight.
A resident was administered Risperidone, an antipsychotic medication, without an approved diagnosis or documented physician rationale for its use. The resident had multiple mental health diagnoses and required significant assistance, but the facility did not meet policy requirements for psychotropic medication use, including proper documentation and physician certification.
A resident with severe cognitive impairment and a diagnosis of neurocognitive disorder with Lewy bodies was administered quetiapine, an antipsychotic, without a documented physician rationale or approved indication. Facility records and medication monitoring lacked evidence of abnormal behaviors or justification for the medication, and psychiatry had not assessed the resident, resulting in noncompliance with facility policy on psychotropic medication use.
A resident with dementia, major depressive disorder, and Parkinson's disease was administered Seroquel without clear documentation of the targeted behaviors, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Physician orders listed varying diagnoses for the antipsychotic use, and the care plan lacked specific behavioral indications, resulting in a deficiency related to unnecessary psychotropic medication use.
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