Psychotropic drugs · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F758 in Massachusetts. Pick another state for the same tag.
Against expectation — 2025
Massachusetts cites F758 more often than its own record predicts
Versus expected share1.47×
1.47 times the share F758 takes of citations nationally.
Share of Massachusetts citations0.93%
Of every deficiency written in Massachusetts in 2025, this is the portion that was F758.
Massachusetts0.93%
National0.63%
Share of all citations that were F758.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F758 findings written in Massachusetts, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternMay 11, 2021
Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure Resident #1 was free from the administration of unnecessary [CONDITION(S)] medications (medications that affect brain activity associated with mental processes and behavior). Upon admission to the Facility in January 2021, in addition to Resident #1 physician ordered medications, which include two [CONDITION(S)] medications, another patients hospital discharge medication list was included in Resident #1's Hospital discharge packet and as a result, three additional [CONDITION(S)] medications were ordered and administered, in error, to Resident #1 during his/her admission to the Facility, (for greater than 30 days). …
2.) Resident #109 was admitted in 5/2021 with diagnoses including dementia and major depressive disorder.
Review of the Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #109 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment.
Review of the facility policy titled Psychotropic Medication, dated 4/2022, indicates the following
- The consultant pharmacist reviews the appropriateness of the psychoactive medication order as part of each drug regimen review and monitors for;
- Appropriateness of psychoactive administration based on diagnosis, clinical indications and prescribing guidelines and;
- Reassessment for trial reduction in dose in accordance with state/federal regulations. …
D · No harm, potential for more than minimal, isolatedApril 30, 2025
Based on records reviewed and interview, the facility 1) failed to ensure one Resident (#71) was free from unnecessary medications by not reassessing a PRN (as needed) psychotropic medication and 2) failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#47) who was receiving antipsychotic medications out of a total sample of 24 Residents.
Findings include:
The surveyors asked for polilcies for the as needed psychotropic medication and AIMS assessments and they were not provided to them.
1. Resident #71 was admitted to the facility in November 2024 with diagnoses including depression and Alzheimer's Disease. …
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