Your task is to read through what was observed and determine what Ftags would have been issued for this observation and what the plan of correction should be to correct it.

Based on interview and document review, the facility had not identified resident specific indications for use for [MEDICAL CONDITION] medications, nor monitored for effectiveness of the psychoactive medication, nor attempted to use non-pharmacological interventions  before using psychoactive medications for 2 of 5 residents (R21, R22) also no clinical  symptoms were identified to justify the increase in an antidepressant medication for 1 of  5 residents (R5) who had been reviewed for unnecessary medications. Findings include: Lack of clear indication of use of psychoactive medication. Lack of non-pharmacological interventions attempted before use of psychoactive medication, lack of effectiveness of psychoactive as needed (PRN) use: R21 had been admitted on [DATE] according to the face sheet. R21’s physician progress notes [REDACTED]. Review of R21’s significant change minimum data set ((MDS) dated [DATE], identified Brief Interview for Mental Status (BIMS) score of six, severe cognitive impairment. Review of R21’s physician orders [REDACTED]. Review of R21’s nurse’s notes dated 8/16/14, revealed resident very anxious and restless with difficulty breathing, new order for [MEDICATION NAME] 0.5 mg TID PRN for anxiety, further review of R21’s progress notes dated 8/15/14 through 10/1/14 identified no specific symptoms for use of [MEDICATION NAME] or non-pharmacological interventions tried before obtaining order for [MEDICATION NAME] had been documented. Review of R21’s physician progress notes [REDACTED]. Document review of R21’s care plan dated 9/26/14, identified problem of but not limited to fluid volume excess related to [MEDICAL CONDITION] and approaches of but not limited to report anxiety/restlessness. R21’s care plan had no documentation of specific symptoms related to [MEDICATION NAME] use. Document review of R21 medication/treatment summary report and recent PRN med use sheets for month of 9/14, revealed anti-anxiety monitor for behavior symptoms rejects care, [MEDICATION NAME] 0.5 mg three times a day as needed for anxiety and [MEDICATION NAME] 0.5 mg had been administered on 9/20/14 given for anxiety, breathing heavy, cannot sit still and on 9/25/14 for anxiety problems breathing. No specific symptoms had been identified for use of [MEDICATION NAME], effectiveness of medication after administration on 9/20/14 had not been documented and no documentation of Non-pharmacological interventions tried before administration of [MEDICATION NAME] on 9/20/14 and 9/25/14 had been documented. Review of R21’s psychoactive medication quarterly evaluation dated 9/2/14 identified drug:  [MEDICATION NAME], dosage: 0.5 mg, frequency: TID PRN, Diagnosis: [REDACTED]. During interview on 10/2/14, at 9:13 a.m., director of nursing had stated would expect physician to address [MEDICATION NAME] on rounds, especially since it was a change. Director of nursing had stated would expect effectiveness of [MEDICATION NAME] to be documented and non-pharmacological intervention tried before giving the [MEDICATION NAME]. Policy for PRN [MEDICAL CONDITION] medications had been requested but not provided.   R22 was admitted on [DATE] according to the face sheet. The physician’s progress notes dated 9/17/14 identified R22’s [DIAGNOSES REDACTED]. Review of R22’s significant change minimum data set ((MDS) dated [DATE], identified Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. R22 scored 0 on the Patient Health Questionnaire (PHQ-9) indicating no signs or symptoms of depression. Review of R22’s physician’s order [REDACTED]. Instructions: Don’t administer if over sedated, confused, dizzy, etc. Monitor every 3 months. Please try non-medication therapies before giving the [MEDICATION NAME]-document the therapies and the outcome. Also, the orders included [MEDICATION NAME] Extended Release (an antidepressant) 37.5 mg capsule by mouth daily for major [MEDICAL CONDITION]. The psychoactive medication quarterly evaluation for the use of [MEDICATION NAME] dated 5/9/14 indicated that no behaviors noted at this time. History of refusing cares, but none in last week. MD can review on rounds if change is needed. The psychoactive quarterly evaluation dated 8/11/14 for the use of [MEDICATION NAME] indicated that behavior warranting use of medication was refusal of cares. The monthly behavior monitoring flow sheets for the months dated December, 2013 through August 2014 was reviewed for the use of [MEDICATION NAME] and [MEDICATION NAME]. The flow sheets indicated the behavior for [MEDICATION NAME] being monitored was anxiety, about not being able to return home. The behavior for [MEDICATION NAME] being monitored was refusal of cares. Documentation indicated that no behaviors were noted. The MDS dated [DATE] indicated no rejection of cares. Review of the PRN (as needed) medication record for the month of September, 2014 indicated that R22 received [MEDICATION NAME] 7 times for anxiety, restless, anxiety for going to the dentist, agitation, on call light not sure of need, difficulty transferring, legs are crawling and cannot settle down for bed. In August 2014 R22 received [MEDICATION NAME] 3 times for anxiety, and for July 2014, R22 received [MEDICATION NAME] 8 times for anxiety, too anxious to sleep, I’ve worked myself into a tizzy and I don’t know why, unable to sleep. R22’s care plan dated 2/18/14 had a problem titled psychosocial well- being related to depression/situational anxiety. The interventions included to provide protection to resident and assure resident of personal   concerns and her welfare, give medications prescribed by physician to treat depression and for situational anxiety, follow resident ‘ s activities to see what causes situations anxiety to defuse those situations, re approached 10-15 minutes later, try different staff member. Targeted behaviors were refusal of cares, anxious of not being able to return home. A review of the nurse’s notes from June 2014 through September 30, 2014 showed no documentation of non-pharmacological interventions prior to giving the [MEDICATION NAME]. A review of the monthly pharmacy review dated 6/16/14 indicated that the pharmacist would address with the director of nursing (DON) again regarding no non-pharmacological documentation prior to administration of the as needed psych needs. During an interview with the nursing assistant (NA)-B on 10/1/14 at 9:30 a.m., NA-B indicated that she wasn’t aware of or had seen any behaviors with R22. During an interview with NA -An on 10/1/14 at 9:30 a.m., NA -A stated R22 had no behaviors, but that she didn’t like her bath. R22 didn’t refuse her bath though. During an interview with the licensed practical nurse (LPN)-An on 10/2/14 at 9:30 a.m., LPN-An indicated that R22 a few times here and there shows signs of depression, mostly to do with her family. Normally one on ones worked for R22. If R22 would get overly anxious, then they give her a prn (as needed) [MEDICATION NAME]. LPN-A stated she thought R22’s issues had more to do in the transition period of when she first came to the nursing home (admission was August 2013.) During an interview with R22 on 10/2/14 at 9:35 a.m., R22 indicated that after she’s been in bed awhile she gets anxious. R22 stated she worried about her kids. R22 indicated that she puts pillows under her legs for restless legs. R22 stated that she had a dentist appointment today to get a filling and that she didn’t like the dentist and sometimes she needs an [MEDICATION NAME]. She tells the staff when she needs an [MEDICATION NAME]. R22 indicated that she had no sadness and stated she liked it here. When asked about taking a bath, R22 indicated that she used to only get one bath a week when she first got here and that wasn’t enough so she asked for two a week. During interview with the director of nursing (DON) on 10/2/14, the DON stated that he feels R22 does make request and needs the [MEDICATION NAME] from time to time. DON indicated he knows he needs to flush out more on what the staff is giving the [MEDICATION NAME] for and what behaviors. DON stated the behaviors needed to be more specific on when R22 needed the [MEDICATION NAME]. DON stated that the staff does provide non-pharmacological interventions but they weren’t good at documenting them.  Lack of clinical symptoms to justify the increase of an antidepressant medication: R5’s provider orders signed 9/3/14 identified R5 had [DIAGNOSES REDACTED]. R5’s annual Minimum  Data Set ((MDS) dated [DATE] 14 indicated R5 had a brief interview for mental status (BIMS) score of 11 indicating moderate cognitive impairment and R5 scored 0 on the PHQ-9   (Patient Health Questionnaire) indicating no signs or symptoms of depression. R5’s provider orders dated 9/3/14 included [MEDICATION NAME] ([MEDICATION NAME] an antidepressant) 40 milligrams (mg) daily. On 7/7/14, the [MEDICATION NAME] was increased to 40 mg daily from 20 mg daily. The physician’s nursing home visit note, dated 7/8/14 read, History of [MEDICAL CONDITION] and anxiety. Is in remission. We did back down on her [MEDICATION NAME] from 40 mg to 20 mg; however, note that her anxiety and some of the other symptoms she is having seems to be increasing, so we will increase her [MEDICATION NAME] back from 20 mg to 40 mg a day and will see if these symptoms resolve. However, there was no information provided when requested by the facility in regards to R5 having anxiety and some of the other symptoms she is having seems to be increasing as the physician wrote in his progress note dated 9/3/14 to support the decision to increase the [MEDICATION NAME] dose. R5’s monthly behavior monitoring flow sheet dated July 2014 revealed R5 received [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The progress notes provided from the facility from 12-5-13 to 9-11-14 revealed only one entry had been made regarding mood concerns for R5. The progress note dated 6/22/14 indicated the resident had requested something for her nerves and the physician was contacted and the facility received an order for [REDACTED]. On 10/2/14 at 9:36 a.m. the director of nursing (DON) stated the progress note dated 6/22/14 justified the need for the increase in [MEDICATION NAME] as R5 had requested something for her nerves. The DON verified this was the only documentation the facility had to support the gradual dose reduction failure for [MEDICATION NAME] and the need to increase the [MEDICATION NAME] back to the original dose of 40 mg a day. Based on interview and document review, the pharmacist had not identified on monthly  medication assessments the lack of resident specific indications for use for psychotropic medications, nor monitored for effectiveness of the psychoactive medication, nor attempted to use non-pharmacological interventions before using psychoactive medications for 2 of 5 residents (R21, R22) also no clinical symptoms were identified to justify the increase in an antidepressant medication for 1 of 5 residents (R5) who had been reviewed for unnecessary medications. Findings include: Lack of clear indication of use of psychoactive medication. Lack of non-pharmacological interventions attempted before use of psychoactive medication, lack of effectiveness of psychoactive as needed (PRN) use: R21 had been admitted on [DATE] according to the face sheet. R21’s physician progress notes [REDACTED]. Review of R21’s significant change minimum data set ((MDS) dated [DATE], identified Brief Interview for Mental Status (BIMS) score of six, severe cognitive impairment. Review of R21’s physician orders [REDACTED]. Review of R21’s nurse’s notes dated 8/16/14, revealed resident very anxious and restless with difficulty breathing, new order for Ativan 0.5 mg TID PRN for anxiety, further review of R21’s progress notes dated 8/15/14 through 10/1/14 identified no specific symptoms for use of Ativan or non-pharmacological interventions tried before obtaining order for Ativan had been documented. Review of R21’s physician progress notes [REDACTED]. Document review of R21’s care plan dated 9/26/14, identified problem of but not limited to fluid volume excess related to congestive heart failure and approaches of but not limited to report anxiety/restlessness. R21’s care plan had no documentation of specific symptoms related to Ativan use. Document review of R21 medication/treatment summary report and recent PRN med use sheets for month of 9/14, revealed anti-anxiety monitor for behavior symptoms rejects care, Ativan 0.5 mg three times a day as needed for anxiety and Ativan 0.5 mg had been administered on 9/20/14 given for anxiety, breathing heavy, cannot sit still and on 9/25/14 for anxiety problems breathing. No specific symptoms had been identified for use of Ativan, effectiveness of medication after administration on 9/20/14 had not been documented and no documentation of Non-pharmacological interventions tried before administration of Ativan on 9/20/14 and 9/25/14 had been documented. Review of R21’s psychoactive medication quarterly evaluation dated 9/2/14 identified drug: Ativan, dosage: 0.5 mg, frequency: TID PRN, Diagnosis: [REDACTED]. During interview on 10/2/14, at 9:13 a.m., director of nursing had stated would expect physic R22 was admitted on [DATE] according to the face sheet. The physician’s progress notes dated 9/17/14 identified R22’s [DIAGNOSES REDACTED]. Review of R22’s significant change minimum data set ((MDS) dated [DATE], identified Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. R22 scored 0 on the Patient Health Questionnaire (PHQ-9) indicating no signs or symptoms of depression. Review of R22’s physician’s order [REDACTED]. Instructions: Don’t administer if over sedated, confused, dizzy, etc. Monitor every 3 months. Please try non-medication therapies before giving the Ativan-document the therapies and the outcome. Also, the orders included Effexor Extended Release (an antidepressant) 37.5 mg capsule by mouth daily for major depressive disorder. The psychoactive medication quarterly evaluation for the use of Effexor dated 5/9/14 indicated that no behaviors noted at this time. History of refusing cares, but none in last week. MD can review on rounds if change is needed. The psychoactive quarterly evaluation dated 8/11/14 for the use of Effexor indicated that behavior warranting use of medication was refusal of cares. The monthly behavior monitoring flow sheets for the months dated December, 2013 through August 2014 was reviewed for the use of Effexor and Ativan. The flow sheets indicated the behavior for Ativan being monitored was anxiety, about not being able to return home. The behavior for Effexor being monitored was refusal of cares. Documentation indicated that no behaviors were noted. The MDS dated [DATE] indicated no rejection of cares. Review of the PRN (as needed) medication record for the month of September, 2014 indicated that R22 received Ativan 7 times for anxiety, restless, anxiety for going to the dentist, agitation, on call light not sure of need, difficulty transferring, legs are crawling and cannot settle down for bed. In August 2014 R22 received Ativan 3 times for anxiety, and for July 2014, R22 received Ativan 8 times for anxiety, too anxious to sleep, I’ve worked myself into a tizzy and I don’t know why, unable to sleep. R22’s care plan dated 2/18/14 had a problem titled psychosocial well- being related to depression/situational anxiety. The interventions included to provide protection to resident and assure resident of personal concerns and her welfare, give medications prescribed by physician to treat depression and for situational anxiety, follow resident ‘ s activities to see what causes situations anxiety to defuse those situations, re approached 10-15 minutes later, try different staff member. Targeted behaviors were refusal of cares, anxious of not being able to return home. A review of the nurse’s notes from June 2014 through September 30, 2014 showed no documentation of non-pharmacological interventions prior to giving the Ativan. A review of the monthly ian to address Ativan on rounds, especially since it was a change. Director of nursing had stated would expect effectiveness of Ativan to be documented and non-pharmacological intervention tried before giving the Ativan. Policy for PRN psychotropic medications had been requested but not provided.

R22 was admitted on [DATE] according to the face sheet. The physician’s progress notes dated 9/17/14 identified R22’s [DIAGNOSES REDACTED]. Review of R22’s significant change minimum data set ((MDS) dated [DATE], identified Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. R22 scored 0 on the Patient Health Questionnaire (PHQ-9) indicating no signs or symptoms of depression. Review of R22’s physician’s order [REDACTED]. Instructions: Don’t administer if over sedated, confused, dizzy, etc. Monitor every 3 months. Please try non-medication therapies before giving the Ativan-document the therapies and the outcome. Also, the orders included Effexor Extended Release (an antidepressant) 37.5 mg capsule by mouth daily for major depressive disorder. The psychoactive medication quarterly evaluation for the use of Effexor dated 5/9/14 indicated that no behaviors noted at this time. History of refusing cares, but none in last week. MD can review on rounds if change is needed. The psychoactive quarterly evaluation dated 8/11/14 for the use of Effexor indicated that behavior warranting use of medication was refusal of cares. The monthly behavior monitoring flow sheets for the months dated December, 2013 through August 2014 was reviewed for the use of Effexor and Ativan. The flow sheets indicated the behavior for Ativan being monitored was anxiety, about not being able to return home. The behavior for Effexor being monitored was refusal of cares. Documentation indicated that no behaviors were noted. The MDS dated [DATE] indicated no rejection of cares. Review of the PRN (as needed) medication record for the month of September, 2014 indicated that R22 received Ativan 7 times for anxiety, restless, anxiety for going to the dentist, agitation, on call light not sure of need, difficulty transferring, legs are crawling and cannot settle down for bed. In August 2014 R22 received Ativan 3 times for anxiety, and for July 2014, R22 received Ativan 8 times for anxiety, too anxious to sleep, I’ve worked myself into a tizzy and I don’t know why, unable to sleep. R22’s care plan dated 2/18/14 had a problem titled psychosocial well- being related to depression/situational anxiety. The interventions included to provide protection to resident and assure resident of personal concerns and her welfare, give medications prescribed by physician to treat depression and for situational anxiety, follow resident ‘ s activities to see what causes situations anxiety to defuse those situations, re approached 10-15 minutes later, try different staff member. Targeted behaviors were refusal of cares, anxious of not being able to return home. A review of the nurse’s notes from June 2014 through September 30, 2014 showed no documentation of non-pharmacological interventions prior to giving the Ativan. A review of the monthly pharmacy review dated 6/16/14 indicated that the pharmacist would address with the director of nursing (DON) again regarding no non-pharmacological documentation prior to administration of the as needed psych needs. During an interview with the nursing assistant (NA)-B on 10/1/14 at 9:30 a.m., NA-B indicated that she wasn’t aware of or had seen any behaviors with R22. During an interview with NA -An on 10/1/14 at 9:30 a.m., NA -A stated R22 had no behaviors, but that she didn’t like her bath. R22 didn’t refuse her bath though. During an interview with the licensed practical nurse (LPN)-A on 10/2/14 at 9:30 a.m., LPN-A indicated that R22 a few times here and there shows signs of depression, mostly to do with her family. Normally one on ones worked for R22. If R22 would get overly anxious, then they give her a prn (as needed) Ativan. LPN-A stated she thought R22’s issues had more to do in the transition period of when she first came to the nursing home (admission was August 2013.) During an interview with R22 on 10/2/14 at 9:35 a.m., R22 indicated that after she’s been in bed awhile she gets anxious. R22 stated she worried about her kids. R22 indicated that she puts pillows under her legs for restless legs. R22 stated that she had a dentist appointment today to get a filling and that she didn’t like the dentist and sometimes she needs an Ativan. She tells the staff when she needs an Ativan. R22 indicated that she had no sadness and stated she liked it here. When asked about taking a bath, R22 indicated that she used to only get one bath a week when she first got here and that wasn’t enough so she asked for two a week. During interview with the director of nursing (DON) on 10/2/14, the DON stated that he feels R22 does make request and needs the Ativan from time to time. DON indicated he knows he needs to flush out more on what the staff is giving the Ativan for and what behaviors. DON stated the behaviors needed to be more specific on when R22 needed the Ativan. DON stated that the staff does provide non-pharmacological interventions but they weren’t good at documenting them. Lack of clinical symptoms to justify the increase of an antidepressant medication: R5’s provider orders signed 9/3/14 identified R5 had [DIAGNOSES REDACTED]. R5’s annual Minimum Data Set ((MDS) dated [DATE] 14 indicated R5 had a brief interview for mental status (BIMS) score of 11 indicating moderate cognitive impairment and R5 scored 0 on the PHQ-9 (Patient Health Questionnaire) indicating no signs or symptoms of depression. R5’s provider orders dated 9/3/14 included citalopram (Celexa an antidepressant) 40 milligrams (mg) daily. On 7/7/14, the Celexa was increased to 40 mg daily from 20 mg daily. The physician’s nursing home visit note, dated 7/8/14 read, History of major depression and anxiety. Is in remission. We did back down on her Celexa from 40 mg to 20 mg; however, note that her anxiety and some of the other symptoms she is having seems to be increasing, so we will increase her Celexa back from 20 mg to 40 mg a day and will see if these symptoms resolve. However, there was no information provided when requested by the facility in regards to R5 having anxiety and some of the other symptoms she is having seems to be increasing as the physician wrote in his progress note dated 9/3/14 to support the decision to increase the Celexa dose. R5’s monthly behavior monitoring flow sheet dated July 2014 revealed R5 received Celexa for a [DIAGNOSES REDACTED]. The progress notes provided from the facility from 12-5-13 to 9-11-14 revealed only one entry had been made regarding mood concerns for R5. The progress note dated 6/22/14 indicated the resident had requested something for her nerves and the physician was contacted and the facility received an order for [REDACTED]. On 10/2/14 at 9:36 a.m. the director of nursing (DON) stated the progress note dated 6/22/14 justified the need for the increase in Celexa as R5 had requested something for her nerves. The DON verified this was the only documentation the facility had to support the gradual dose reduction failure for Celexa and the need to increase the Celexa back to the original dose of 40 mg a day.