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 Oregon. Pick another state for the same tag.
Against expectation — 2025
Oregon cites F758 more often than its own record predicts
Versus expected share1.16×
1.16 times the share F758 takes of citations nationally.
Share of Oregon citations0.73%
Of every deficiency written in Oregon in 2025, this is the portion that was F758.
Oregon0.73%
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 Oregon surveyors wrote
F758 findings written in Oregon, 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.
G · Actual harm, isolatedFebruary 11, 2021
Based on observation, interview and record review it was determined the facility failed to ensure a PRN order for an antipsychotic was not in place for more than 14 days, failed to to identify or monitor targeted behaviors for the use of an antipsychotic and failed to have a system in place to determine the efficacy of an antipsychotic and communicate such to the physician for 3 of 3 sampled residents (#s 16, 18 and 19) reviewed for unnecessary medications. This failure resulted in new and prolonged significant change in alertness for Resident 16. Findings include:
1. Resident 16 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired. …
D · No harm, potential for more than minimal, isolatedApril 24, 2025
Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 of 5 sampled residents (#177) reviewed for unnecessary medication. This placed residents at risk for adverse side effects. Findings include:
Resident 177 was admitted to the facility in 4/2025 with diagnoses including anxiety and sleep apnea (pause in breathing during sleep).
Review of the clinical record on 4/22/25 revealed Resident 177 was ordered PRN Lorazepam (for anxiety) every six hours starting on 4/4/25. …
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