The facility failed to ensure physician review of pharmacy GDR recommendations and failed to include stop dates on PRN psychotropic orders for several residents. A resident had PRN Klonopin without a stop date, two PRN lorazepam orders also lacked stop dates, and pharmacy recommendations for dose reduction of psychotropics for two cognitively intact residents remained unaddressed. The DON confirmed the unaddressed recommendations and missing stop dates.
A resident with dementia and moderately impaired cognition was receiving quetiapine for hallucinations and sertraline for depression, but the facility did not attempt or document a GDR for the psychotropic medications. The MDS noted no GDR had been documented as clinically contraindicated, and interviews with the DON, pharmacy consultant, NP, attending physician, and Administrator confirmed the GDR was missed.
A resident with dementia and severely impaired cognition had active PRN orders for Lorazepam and Diazepam that were entered without required 14-day stop dates, contrary to facility policy and federal requirements. Policy required all PRN psychotropic medications to be limited to a 14-day duration unless a physician documented clinical rationale and specified a longer duration. Review of records and a pharmacy consultant report showed the PRN psychotropic orders remained active beyond 14 days without documented physician justification or renewal. The DON, Administrator, and pharmacy consultant each confirmed that these PRN psychotropic orders should have been time-limited and either discontinued or renewed with appropriate documentation.
A resident with severe cognitive impairment and dementia was administered Haldol and Sertraline without documented consent from their representative, despite facility policy requiring informed consent for psychotropic medications. The DON confirmed that no consent forms were found, and the representative was unaware of the medications until after requesting a list.
A resident was prescribed multiple antipsychotic medications, including Olanzapine and Haloperidol, for indications such as mood and psychosis, despite medical records only documenting depression and no other psychiatric or mood disorders. Staff interviews revealed that the pharmacist and nursing staff relied on general processes for associating diagnoses with medication orders, but the documentation did not support the clinical need for these antipsychotic prescriptions.
A resident with schizophrenia and major depressive disorder had a PRN order for Haldol Decanoate that was not discontinued after the required fourteen-day period, as confirmed by facility policy and staff interviews. The order remained active despite not being administered, and the oversight was attributed to human error by the DON.
A resident with insomnia received a PRN order for Zolpidem, and although the pharmacist and provider approved a six-month extension, facility staff failed to document the required stop date in the medication orders. Both the RN/MDS and DON confirmed the omission, resulting in the absence of a mandated stop date for the psychotropic medication.
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