A resident with COPD, muscle weakness, difficulty walking, and need for assistance with personal care had orders for duloxetine for depression, trazodone for insomnia, and PRN clonazepam for insomnia/anxiety. The chart lacked documented behavior monitoring for the psychotropic meds, the cMDS did not identify an active diagnosis for the antianxiety and antidepressant meds, and the record did not clearly document an indication for insomnia. The LPN/UM confirmed behavior monitoring should be in the eMAR, and the DON stated the clonazepam order and behavior monitoring were clarified after the surveyor’s inquiry.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Inadequate monitoring and inappropriate diagnosis for antipsychotic use: A resident with severe cognitive impairment and dementia-related behaviors received quetiapine and divalproex, but the MDS did not show an active diagnosis for the antipsychotic, the care plan did not list target behaviors, and behavior monitoring was not documented when the antipsychotic was started or increased. The psych APRN described restlessness in the evenings without aggression or psychotic symptoms, while the LPN, UM, and DON stated that target behaviors and monitoring should be documented and that restlessness and agitation were not appropriate diagnoses for the antipsychotic.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Failure to follow up on a psychiatrist’s recommended GDR for quetiapine. A resident with major depressive disorder, PTSD, and paranoid schizophrenia was receiving antipsychotic medication, and the psych note recommended reducing Seroquel from 50 mg HS to 25 mg HS for 7 days, then discontinuing it. The MAR showed the medication continued as ordered, but the chart lacked documentation that the PCP or resident representative addressed the recommendation, and the consultant pharmacist also noted the need for follow-up.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.