**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: 2568667.Based on interview and record review, the facility failed to prevent the use of unnecessary psychotropic medications without adequate indication for use and without resident monitoring in 1 of 1 resident (Resident #101) reviewed for psychotropic medications, resulting in an Immediate Jeopardy when on [DATE] Resident #101 was prescribed a psychotropic medication, who then sustained a fall with a impacted acetabulum (hip socket) and pelvic fracture on [DATE] and subsequent death. Findings include: Resident #101 was prescribed lorazepam daily beginning [DATE]. Resident #101 had falls on 5/12, 5/20, and 5/28 with no major injury after no falls since February admission. No monitoring for or recognition of adverse consequences from psychotropic medications occurred after these falls. On [DATE], Resident #101 fell while ambulating and sustained impacted acetabulum and pelvic fractures, was hospitalized , and died as a result of the fall per the medical examiner.The Immediate Jeopardy began on [DATE] when Resident #101, who was prescribed lorazepam daily beginning [DATE] and had falls on 5/12, 5/20, and 5/28 with no major injury after no falls since February admission. No monitoring for or recognition of adverse consequences from psychotropic medications occurred after these falls. On [DATE], Resident #101 fell while ambulating and sustained impacted acetabulum and pelvic fractures, was hospitalized , and died as a result of the fall per the medical examiner. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 2:24 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at actual harm due to not all staff had received education and sustained compliance had not been verified by the State Agency. Review of an admission Record revealed Resident #101 was a female with pertinent diagnoses which included severe late onset Alzheimer's dementia with agitation, recurrent falls, insomnia, and depression. Review of Minimum Data Set (MDS) dated [DATE] revealed, a Brief Mental Status Score (BIMS): 11 which indicated moderate cognitive impairment.Review of Care Plan for Resident #101, started on [DATE], revealed Resident #101 was at risk for falls due to impaired balance, did not ask for assistance, but prefers to remain independent. Resident #101 was on psychoactive medications which increase her risk. Interventions included Monitor medication side effects for potential gait disturbances or other safety issues and Visual checks per facility policy. Note: Requested policy for visual checks and was informed the facility does not have a policy for visual checks. Review of Resident Care Summary dated [DATE], revealed, .Independent: Bed Mobility, Chair to Bed/Chair transfers, and Walk 10 feet. Review of electronic correspondence received from Director of Nursing (DON) B on [DATE] revealed, fall dated [DATE] occurred at 5:10 AM. Review of Event Summary Report dated [DATE], revealed, CENA alerted by roommate that resident had fallen. Resident was lying on her back parallel to the bed. She had just come out of the bathroom at the time of fall per roommate. C/O (complaint of) increased pain to the L (left) hip.Unable to properly assess the L hip d/t (due to) pain. Placed pillows under her to make her more comfortable and called (Initial) the On-call Provider to have her transported to the ER for an eval. No indication that Resident #101's medications were reviewed at the time of fall to determine if they contributed to the fall despite an increase in behaviors after starting Lorazepam. In an interview on [DATE] at 11:00 AM, Registered Nurse (RN) M reported when she went into the room, Resident #101 was on the floor on her R (Right) side. Resident #101 was in a lot of pain. RN M reported she wanted to do her own thing and was angry at staff when staff checked on her because she felt she could do it herself. In an interview on [DATE] at 3:25 PM, CNA II reported Resident #101 had gotten up, went to the bathroom and the roommate had turned on the call light to alert us. CNA II reported she went into the room and found Resident #101 on the floor between her and her roommate's bed, and she was in a lot of pain. CNA II reported Resident #101 was independent, she liked to do a lot of things herself, and she didn't like staff to assist her, but was not aggressive or combative.Review of ED Triage Notes dated [DATE] revealed, .Closed displaced combined transverse-posterior fracture of left acetabulum; ground level fall. (complex fracture of the left hip socket's bony structure, characterized by a break that runs across the socket and extends to its posterior (back) wall, is not open to the outside (closed) and has bone fragments that have moved out of alignment).Review of CT of the Pelvis without Intravenous Contrast dated [DATE] at 7:45 AM, revealed, .Impression: 1. Complex and displaced left acetabular fracture with extension into the left iliac wing resulting in a posttraumatic protrusion appearance of the femoral head.2. Mild to moderately angulated and minimally displaced fracture of the left inferior pubic ramus.Review of Geriatric Trauma Consult dated [DATE] at 8:29 AM, revealed, . She is planned for fixation of her displaced acetabular fracture.Falls: -unwitnessed, patient with 3 other falls in May, may be mechanical/med (medication) associated - has had increasing falls since starting lorazepam on 5/9.-Symptoms associated with the fall not clear as patient had unwitnessed fall.-Falls in the past 6 months Yes - 3 other falls in May. one fall in February. taking lorazepam, which can increase fall risk, poor strength. Geriatric Assessment: Patient's daughter/DPOAH (FM OO) is at the bedside. Reviewed how (Resident #101) had been living in LTC since February as she was having more falls. Prior to that she had lived with (FM OO). Discussed how she has had 3 falls in May and now this fall in June. Explained that she has had an increase of falls since starting lorazepam for restlessness and agitation. In an interview on DON B reported Resident #101 returned back to the facility following the fall on [DATE] on hospice services. Review of (Medical Examiner) autopsy report received on [DATE] revealed, . CONCLUSION: Based upon the examination findings and the history as available to me, it is my opinion that (Resident #101) died as a result of the sequelae (consequences of) of left-sided pelvic fractures. Alzheimer's dementia is contributory to the death.CAUSE OF DEATH: Sequelae of left-sided pelvic fractures.In an interview on [DATE] at 3:27 PM, Family Member (FM) OO reported Resident #101 had a fall at home and was admitted to the facility following evaluation at the hospital. FM OO reported when Resident #101 was admitted to the hospital following the last fall on [DATE], she was informed Resident #101 was being given Ativan at night she reported she was not aware nor was she contacted to discuss the addition of the medication or provide her consent. FM OO reported Resident #101's hip bone broke and went through her pelvis. FM OO reported Resident #101 never had aggressive, never had angry behaviors, she was a very, very active and continued to be able to walk prior to this last fall on [DATE] and due to that mobility, she felt Resident #101 shouldn't have received Ativan. FM OO reported Resident #101 was more active at night, got up frequently and believed she had sundowners. FM OO reported Resident #101 had surgery to correct the fractures and returned to the facility on hospice services, and Resident #101 passed a few weeks later. FM OO reported the medical examiner report indicated Resident #101 died due to the fall she had while at the facility. According to Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies Markota ([NAME] et al. Mayo Clinic Proceedings, Volume 91, Issue 11, 1632 - 1639) .This widespread prescription of benzodiazepines in a population for which they are generally contraindicated because benzodiazepine use is associated with risk of dependence, cognitive deficits, falls resulting in fractures, and overall mortality .Elderly patients in residential care facilities are at a higher risk of being exposed to benzodiazepines. Use of benzodiazepines in elderly patients with a history of falls recommendation is to avoid benzodiazepines .These drugs possess minimal efficacy in treating insomnia beyond acute periods measured in days and considerably increase the risk of adverse effects, including delirium, falls, and fractures .In the elderly, however, even short-term use of benzodiazepines can have dangerous adverse effects .With regard to older adults with particularly high risk of falls and fractures, patients who frequently use the restroom at night, and those with a history of falls are particularly vulnerable . Review of Psychotropic Medication Risk/Benefit Consent [DATE] revealed, Resident #101 nor FM OO had provided consent for the Ativan orders. In an interview on [DATE] at 09:07 AM, Social Worker (SW) H reported consents for medications would be signed electronically by the decision maker or resident when admitted or when there was a change in medications where consents were needed. SW H was unable to locate notes for Resident #101 as well as notes which had indicated a conversation had been had with the decision maker for the medication. During an observation and interview on [DATE] at 2:32 PM, Nurse Liaison C reported during review of Resident #101's chart she only had the consent for an antidepressant, and a note from provider dated [DATE] to start the Ativan, and no documentation in the note of having a conversation with the FM OO. Review of Progress Note dated [DATE] at 1:41 PM, revealed, . (Resident #101) is a 87 y.o. female seen today for reports of increased wandering into other patients' rooms at night and agitation. She is alert but confused, as is her baseline.Assessment & Plan: Severe late onset Alzheimer's dementia with agitation: Will add Ativan 0.5 mg po at HS (before bedtime) prn (as needed) x 14 days and reevaluate need for use in 14 days for wandering with intermittent anxiety and agitation. Benefits are felt to outweigh risks of patient distress and risk of safety to self and others with wandering into spaces not intended for her to be able to access. Other insomnia.Melatonin prn, Ativan prn x 14 nights.Review of Resident #101's orders did not show an order for monitoring for adverse effects of psychotropic medications. Review of Resident #101's care plans did not show a focus for monitoring psychotropic medications. Review of Behavior Logs for Resident #101 starting [DATE] through [DATE], revealed Resident #101 was confused, ambulated without assist in room and hallways where redirection was effective in most instances. Resident #101 was noted in bed at appropriate times such as 2100 (09:00 PM), 0000 (12:00 AM), and 0800 (8:00 AM) throughout the multiple months of Resident #101's behavior documentation. The Behavior Logs revealed no increase in wandering or agitation documented until [DATE] at 2000 (8:00 PM) which revealed, Resident #101 was .restless, confusion, refusal, repeating thoughts, agitated.Up in chair. From date [DATE] - [DATE] there were no other documented behaviors. Review of Behavior Logs for Resident #101 revealed, on [DATE] at 0230 (2:30 AM) Resident #101 was found standing in hall, looking for her daughter, knocking on another resident's door and was able to be redirected. At 0430 (4:30 AM) Resident #101 was found standing in hall asking for a phone number. There was no indication of agitation or anxiety. From [DATE] - [DATE] there were no other documented behaviors. Review of Behavior Logs for Resident #101 revealed, on [DATE] and [DATE] resident #101 exhibited behaviors of refusal of assistance/care but was redirectable. From [DATE] - [DATE], there were no other documented behaviors. Review of Care Management Note entered by Nurse Practitioner (NP) H dated [DATE] at 1:10 PM, revealed, .Ativan prn order placed - benefit felt to outweigh risk as patient is quite anxious and argumentative with staff, which seems to make her more likely to attempt to roam the facility talk to staff about things that upset her, increasing her risk for falling. Will reassess in 7 to 14 days and discontinue prn Ativan use if appropriate. Review of Order for Resident #101 dated [DATE], revealed an addition of, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed) .Associated Diagnosis: Anxiety Disorder.Review of MAH for Resident #101 revealed, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed) .Associated Diagnosis: Anxiety Disorder.Given at [DATE] at 1420 (2:20 PM) and Given at [DATE] at 2228 (10:28 PM) . Review of Behavior Log dated [DATE] - [DATE], revealed, Resident #101's behaviors escalated with the use of Lorazepam.Review of the Medical Administration History dated [DATE] to [DATE] revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, nightly, Associated Diagnosis: Other insomnia.Times: 2100 (9:00 PM) revealed, Noted as R (Refused) on [DATE], [DATE], .G (Given) on [DATE], [DATE] - [DATE], [DATE] - [DATE] and then [DATE] - [DATE] - noted as H (Hospital). Review of Event Summary Reports dated [DATE] (no time) revealed Resident #101 had a fall without injury. On [DATE], Resident #101 had a fall that resulted in a small hematoma to the top of her head. Resident #101 was sent to the hospital for review. On [DATE], Per (Registered Nurse (RN) U) .Resident observed on the bathroom floor in her room. Resident sitting on the floor on her bottom. Resident has hematoma (swelling, bruise, or lump) noted to left side of head bleeding with some swelling noted. Resident #101 was sent to the hospital for review and found to have a urinary tract infection at that time. No indication that Resident #101's medications were reviewed after each fall to determine if they contributed to the falls after starting Lorazepam. In an interview on [DATE] at 1:34 PM, Certified Nursing Assistant (CNA) Z reported Resident #101 would get up and go to the bathroom on her own. CNA Z reported when she found Resident #101 on [DATE], she was holding on to the baseboard of her roommate's foot of her bed. CNA Z reported she believed Resident #101 was attempting to ambulate to the bathroom. CNA Z reported Resident #101 was able to walk on her own. CNA Z reported she didn't have any observations of Resident #101 being very aggressive, physical with staff, or swear/call names to staff. In an interview on [DATE] at 1:01 PM, CNA X reported she had placed Resident #101 in her bed on [DATE] and Resident #101 had slipped in the bathroom as she would get up during the night and was not able to make it to the bathroom and she urinated on the floor. CNA X reported Resident #101 would go to bed but then she would get up in the night. In an interview on [DATE] at 12:26 PM, Registered Nurse (RN) U reported on [DATE], the CNA informed her Resident #101 was on the bathroom floor, bleeding. Resident #101 laying on the floor, on her left side, blood was pooling on the floor by her head, there was water or urine on the floor in the bathroom, and she had slipped and fell. RN U reported she assessed the resident, took her vitals, completed range of motion (ROM), cleaned up Resident #101's head as she had a laceration. RN U reported she got an order to send her out to the emergency room (ER). RN U reported Resident #101 was impulsive and would get up whenever, and she wanted to do her own thing. RN U reported the interventions to keep her safe were redirection, bed low, everything in reach for her, nonskid socks. RN U reported when she would get up in the middle of the night, if she was told it was the middle of the night, she would go back to sleep. RN U reported she felt she got up to use the bathroom and with her confusion she slipped and fell. In an interview on [DATE] at 3:53 PM, Licensed Practical Nurse (LPN) QQ and RN L reported she would come and talk to them, could be feisty, wagged her finger at them, had some confusion but she was a fun little lady. LPN QQ reported if she didn't want to do something, she didn't do it. RN L reported she would refuse medications, but he would talk to her, and she would end up taking the medications. In an interview on [DATE] at 12:23 PM, Clinical Nurse Supervisor (CNS) F reported Resident #101 was confused a lot of time, was a cute little lady, she had spent time at the nurse's station, tried to keep extra eyes on her as possible, had multiple conversations in regard to her, felt a memory care unit would be a better option for her. CNS F reported Resident #101 was ambulatory, had a BIMS of 0, and at times she would say some pretty funny stuff, and she had no issues with being combative. CNS F reported there was a behavior log and during morning meeting those were reviewed.In an interview on [DATE] at 11:26 AM, NP D reported she chose to place Resident #101 on Ativan due to her dementia, wandering, and agitation. NP D reported the staff had made multiple attempts to redirect her, she had memory concerns, resident was going into other resident's rooms, and any attempt to intervene she would become agitated and prescribed Ativan to calm Resident #101 down a little bit, so she would wander less. NP H reported medical decision making was a collaboration with the staff and for everyone's benefit. NP H reported she had consulted initially with the pharmacist when she started the Ativan. NP H reported part of her decision-making process, she would speak with the decision maker and in this case the daughter. NP H reported she had spoken in person once with her daughter. NP H reported she may or may not have attempted to call her. NP H reported there was a meeting monthly for residents who were prescribed psychiatric medications, and the resident would be assessed at that meeting for any changes or concerns with the medications and/or behaviors and she would attend that meeting. NP H did not indicate if Resident #101's falls were discussed at these monthly meetings. In an interview on [DATE] at 5:14 PM. Pharmacist RR reported she would review the resident's blood pressure, labs, and check to see if the resident was having behaviors and side effects with those medications, reports of patients of agitation, behavioral log and if the facility had done the GDRs (gradual dose reduction), and within the guidelines. Pharmacist RR reported there was a monthly meeting every third Wednesday where those in attendance discussed if the patient had out of the ordinary type of behaviors and discuss those behavior changes. Pharmacist RR reported a limited view of the electronic medical record as a contractor and had no ability to pull reports such as falls or missed medications and she was very reliant on the facility to provide her with the information when she did her medication reviews. Pharmacist RR reported she was not aware that Resident #101 had an increase in falls after the addition of Lorazepam to her medication regimen. Review of policy, Medication Management - Continuing Care (Rehab and Nursing Centers) dated [DATE], revealed, .The purpose is to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, free from unnecessary drugs and outline the process for safe administration and storage of medications. administration of the medication based on resident response.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Chart Review: [DATE] All residents' charts were reviewed to identify all residents on psychotropic medication to ensure adequate monitoring. A total of 61 residents were identified as taking anti-anxiety medication/ antipsychotics/antidepressants or any mood stabilizers. Worklist task/Order Implementation: [DATE] Worklist tasks have been created for all 61 residents to monitor for adverse reactions to psychotropics. Each task specifies the medication class and symptoms to monitor. Consent forms: [DATE] All residents on psychotropic medications were audited for consent forms. Any resident missing a consent form now has one completed and awaiting signature. The goal is to obtain all signed consents by [DATE]. Completed consent forms will be uploaded to Epic. Provider Education: On [DATE], the Medical Director was educated via telephone by the DON on F605 regulations, with emphasis on the appropriate use of psychotropic medications. A list of all residents on psychotropics was provided. The two Nurse Practitioners will be educated on [DATE]. Behavior Monitoring: Behavior logs are reviewed daily during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents. Nurses were previously educated on [DATE] regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics. The social worker is aware of this expectation, and the second social worker will be educated on [DATE]. Nursing Education: Re-education for nurses began on [DATE], led by the DON, for all nursing leaders and on-duty staff. Education will continue throughout [DATE], and no nurse will be permitted to work until this education is completed after [DATE]. Ongoing Monitoring: The DON or designee will pull an Epic report weekly to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place. New symptoms will be reviewed daily during the IDT meeting and communicated to providers using the SBAR format. Social Work Education: Social workers were previously educated on obtaining consent for psychotropic medications. On [DATE], one social worker was re-educated by the DON, and the second will be re-educated on [DATE]. Consultant Pharmacist Education: On [DATE], the consultant pharmacist was educated by the DON on the medication review process and verbalized understanding.