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.
Based on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 4 of 5 residents (Residents 10, 14, 16, and 66) reviewed for unnecessary psychotropic medications. The facility did not have a system that consistently monitored target behaviors, ensured there were valid indications for use of antipsychotic medications, involved the interdisciplinary team (IDT) in medication management process, considered gradual dose reeducations (GDR), and consistently attempted behavioral interventions prior to medications use. …
Based on interview and record review the facility failed to ensure residents entire drug/medication regimen was managed and monitored to promote or maintain their highest practicable mental, physical, and psychosocial well-being for 3 of 4 Residents (Residents 1, 2, & 38) who received psychotropic medications. Resident 1 experienced harm when the facility continued to administer antipsychotic medication without an approved clinical indication, evaluation of appropriateness, consideration for approved alternative treatments, monitoring, or evidence of non-pharmacological approaches that resulted in psychosocial and physical harm when they were transferred to the hospital due to altered mental status from the adverse effects of antipsychotic medication and was found to have an acute hip… …
D · No harm, potential for more than minimal, isolatedMay 13, 2025
Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 4) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). Failure for the facility to obtain informed consent for treatment with psychotropic drugs and to ensure Resident 4 was monitored for adverse side effects, placed residents at risk of not being fully informed of the risks and benefits of treatment with psychotropic drugs and to receive unnecessary psychotropic drugs.
Findings included .
Review of a facility assessment, dated 03/14/2025, showed Resident 4 had diagnoses which included Cellulitis (an infection of the skin and tissues beneath) of their lower legs, anxiety, and depression. …
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