Failure to Document GDRs for Psychotropic Medications: Two residents with psychiatric diagnoses and intact cognition were receiving multiple psychotropic meds, including antipsychotic, antidepressant, antianxiety, and mood-stabilizing agents. MD and NP notes repeatedly stated moods and behaviors were stable and current meds should continue, but the record did not show a GDR attempt or a documented clinical contraindication for either resident. The DON stated she could not find such documentation in the medical record.
A resident with dementia and severe cognitive impairment was continuously administered Risperidone for agitation without any documented attempt at gradual dose reduction (GDR) or clinical rationale for not doing so, despite facility policy requiring such evaluation and documentation for psychotropic medications.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
Two residents were not protected from unnecessary psychotropic medication use. One received PRN antipsychotic medication without a required 14-day limit or physician documentation for continued use, while another was maintained on the same antidepressant dosages for over a year without any attempt at gradual dose reduction (GDR) or documentation that a GDR was contraindicated. The DON confirmed these deficiencies and the lack of supporting documentation.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
A resident with moderate cognitive impairment and visual hallucinations received PRN Seroquel orders that exceeded the required 14-day limitation. Medical records showed these orders were written for 30 and 60 days, and interviews with the physician, NP, and DON confirmed the orders did not comply with regulations for PRN antipsychotic use.
A resident with severe cognitive impairment and a history of Alzheimer's Disease and adjustment disorder received PRN trazodone for anxiety over several months without the required 14-day reassessment or documentation of a reassessment date, contrary to facility policy. Nursing staff and the DON confirmed that such reassessments are required but were not completed in this case.
A resident with generalized anxiety disorder was given PRN Ativan for pre-appointment anxiety without a required 14-day stop date or documented physician rationale for continued use, contrary to facility policy. Staff interviews confirmed the absence of appropriate stop dates and re-evaluation for the psychotropic medication.
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