A resident with dementia and psychotic disturbance was re-admitted on Zyprexa after the facility had previously completed a successful GDR and discontinued it. The facility did not follow up on why the hospital restarted the antipsychotic, and the record showed no behaviors or other documented clinical indication for continued use. The DON stated she was unsure why the medication was restarted and believed the resident did not need it.
A resident with severe cognitive impairment and multiple medical conditions was administered antipsychotic medication without documented attempts at non-pharmacological interventions, as required by facility policy. Staff did not consistently implement or document behavioral strategies before using medications, and the care plan lacked specific guidance for antipsychotic use.
A resident with multiple medical conditions was prescribed sertraline and trazodone, but staff failed to document monitoring for the efficacy or adverse consequences of these psychotropic medications as required by facility policy. The absence of such monitoring was confirmed through record review and staff interview, with the DON acknowledging the oversight.
A resident with multiple diagnoses, including anxiety disorder and dementia, received PRN Hydroxyzine for anxiety on several occasions without a documented rationale for extended use or a specified duration. Surveyors found no supporting documentation in the medical record, and the DON confirmed the absence of a facility policy specific to PRN psychotropic medication use.
A resident with Alzheimer's disease was prescribed Olanzapine, an antipsychotic, without an appropriate clinical indication or documentation that non-pharmacological interventions were attempted or contraindicated. The medication was ordered for behaviors common in Alzheimer's, such as wandering and lack of safety awareness, which do not alone justify antipsychotic use according to facility policy.
Two residents were administered psychotropic medications without the required baseline AIMS assessments, as mandated by facility policy. One resident with Alzheimer's and dementia received an antipsychotic without any documented AIMS assessment, and another resident with multiple neurological and psychiatric diagnoses was given Memantine and Mirtazapine before an AIMS assessment was completed. This deficiency was identified through record review and staff interviews.
Multiple residents receiving psychotropic medications for conditions such as anxiety, depression, and dementia with agitation did not have individualized behavior monitoring or nonpharmacological interventions documented in their care plans or CNA Kardexes. Staff interviews revealed a lack of training and inconsistent documentation practices, with behaviors often not recorded unless deemed unusual. Facility policies requiring person-centered care planning and nonpharmacological approaches prior to medication use were not followed, resulting in inadequate monitoring and documentation of psychotropic medication effectiveness and necessity.
A resident with a history of anxiety and other chronic conditions continued to receive Lorazepam despite a psychiatric NP's recommendation for gradual dose reduction and discontinuation, as there were no documented behaviors to support ongoing use. The order to discontinue the medication was not processed due to communication lapses among staff, resulting in the resident receiving unnecessary psychotropic medication.
A resident with dementia, depression, and insomnia was given a PRN order for Ativan without a required 14-day limitation or documented physician justification for continued use. The order remained active and the medication was administered multiple times, contrary to facility policy and regulatory requirements.
A resident receiving an antidepressant was not comprehensively assessed for medication use, as required by facility policy. Documentation failed to include specific symptoms of depression, indicators for use, or non-pharmacological interventions. Staff interviews confirmed that comprehensive assessments were not completed, and care plans only addressed monitoring for side effects rather than the clinical rationale for the medication.
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