Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #84) out of 18 sampled residents, was not ordered and administered medications which were not required to treat medical symptoms and resulted in altering the resident's behavior, such that the resident required a lesser amount of effort or care. Observations showed the resident sleeping for prolonged periods of time, had difficulty keeping eyes open when talking, speech was slow and soft with words slow and elongated during enunciation and incontinent. The facility failed to ensure the resident used the least restrictive dosage of medication to treat a medical symptom; failed to address the underlying causes of the distressed behavior; and failed to develop and implement non-pharmalogical individualized interventions prior to administering medications. The facility census was 89 residents. Review of the facility provided Resident [NAME] of Rights, dated 11/2017, showed in part: -The right to be free of physical and chemical restraints. Review of the facility provided policy; Behavior Management and Psycho-Pharmacological Medication Monitoring Protocol, dated 3/2018, showed in part: -Residents who receive antipsychotic, antidepressant, sedative/hypnotic or anti-anxiety medication are to be maintained at the safest lowest dosage necessary to manage the resident's condition. Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications. Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with development of a behavior program. Definitions: -Behavioral Interventions are individualized non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a residents mental, physical and psychosocial well-being. Established resident with new onset of adverse behaviors: -The admitting physician will be notified to rule out medical causes, which may be contributing to the behavior. 1. Review of Resident #84 admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/1/22, showed: -BIMS of 99: indicates the resident's inability to complete the assessment, or severe cognitive defect -Independent for ADLs -Always continent of bowel and bladder -Physical behaviors (such as hitting, kicking or spitting) 1-3 days. -No rejection of cares -Wanders (traveling aimlessly place to place: a typical behavior with dementia diagnosis) 4-6 days -Reading books/magazines, music, current news,going outside, and religious practices are somewhat important to the resident. -Diagnoses: Alzheimer's (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) and Hypertensive Heart Disease (heart problems that occur because of high blood pressure). Review of the resident's Initial Care Plan, dated 10/20/22, showed: -No behaviors noted. Review of the resident's undated Care Plan showed: -Risk for elopement; wanderguard in place, redirect from exits, encourage activities of choice; -Potential to strike out at staff, poor impulse control; Administer medications as ordered, give choices,when becoming agitated intervene, guide away from source of distress, engage calmly in conversation, if no response walk away and approach later. Review of family written undated Care Plan posted on the resident's wall showed: -Please show him/her anything while talking. Point at stuff while talking/explaining things to help him/her get a full understanding and if there are different options involved; -If he/she is not responding or understanding - show him/her; -He/she doesn't need much done for him/her, but explain what he/she is doing and how it will help him/her or you; -We have to follow the rules; -For women- project loudly as he/she has a hard time hearing women's voices; -Go slow, be patient; -Do one thing at a time; -Say things in ways that he/she is helping others by doing what you are having him/her do; -Any way you can say it to help you or him/her, NOT a demand; -He/she had a pool table and likes to play; -He/she enjoys: -Music: 80/90s country, Beach Boys and Monkeys; -TV: Historical, crime/police,comedy, sports events; -He/she does not like westerns or basketball; -Signs of frustration include: -Scratching back of head and slowly becomes more intense; -Looking around, straightening out and not making eye contact - means he/she wants you to go away or stop having him/her do what it is; -Grinding teeth; -A straight blank focused stare; -Shaking of head - like he/she is shaking off what you're telling him/her; -Tight squeezing of hands in and out; - Hitting his/her own head with his/her hands or against something; -This is when he /she is very overwhelmed and peak frustration/anger. During an interview on 11/15/22 at 11:53 A.M., the resident family member said: -prior to coming to the facility, the resident went to the gym three times a week, he/she liked walks, and to watch sporting events; -he/she had specific television shows programmed on the TV for the resident, but the staff will not turn them on for the resident; -staff should not tell the resident what to do. The resident has to be talked to, and the resident will not do something if he/she is told to do it; -the resident is now incontinent, has a shuffling walk, and needs help he/she did not need prior. Review of the resident's medical record showed: -Progress noted dated 8/27/22 at 2:56 P.M.: The resident admitted with a diagnosis of Dementia. He/she was alert and oriented x 2-3, only uses 1-2 words to answer. He/she wanders and is exit seeking. He/she is not aggressive. Review of the Physician Order Sheet (POS), dated 8/27/22, showed: -Donepezil Hcl (a medicine that helps with some types of dementia and can improve memory, attention, the ability to interact with others, speak, think clearly, and perform regular daily activities) 10 milligrams (mg) 1 tablet daily for Alzheimer's, ordered 8/27/22; -Depakote DR (a mood stabilizer that decreases the excitability of brain cells and can cause sedation) 125 mg sprinkle caplets, take 2 tablets three times a day ordered 8/27/22; -Vistaril (a medication used to treat anxiety or itching and may be used as sedation) 25 mg every 8 hours as needed for anxiety, ordered 8/27/22. Record review of the manufacturer's prescribing guidelines for Vistaril showed: -Sedating drugs may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of Vistaril and observed closely; -The effectiveness of hydroxyzine as an antianxiety agent for long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies. The physician should reassess periodically the usefulness of the drug for the individual patient. Record review of the manufacturer's guidelines for Depakote DR showed it has been approved for the following uses: -to treat manic episodes associated with bipolar disorder -alone or with other medicines to treat: complex partial seizures in adults and/or simple and complex absence seizures, with or without other seizure types -to prevent migraine headaches. Review of the resident's medical record showed the resident did not have any of the above indications for use. Record review of the manufacturer's guidelines for Depakote DR showed it can cause drowsiness or sleepiness in the elderly. Review of the resident's medical record, dated 8/27/22 to 9/1/22, showed no documented behaviors, no exit seeking behaviors, and no aggression towards staff or other residents. Review of the resident's medical record showed: - Progress notes, dated 9/1/22 at 5:37 P.M., showed Charge Nurse reported the resident was noted to be agitated, insisting to go home and balled his/her fist as if he/she was going to attempt to strike the 1 to 1 staff member. Attempted to calm the resident and explain the Public Administrator would have to give permission. Resident continued to state he/she wanted to go home. Again explained that leaving the facility was not safe, this seemed to increase residents agitation. He/she smacked him/herself in the head several times, approached the writer and slapped him/her with an open palm in the side of the head. Staff members began to gather to assist and resident slapped his/her own head with open palm, then charged at the writer. 911 called for assistance. Resident transported to area emergency room (ER). - 9/1/22 at 6:22 P.M. The resident was sent out, after he/she balled up fist in 1 to 1 staff members face and demanded for door to be opened and him/her let out. Explained he/she needed to talk with social services and he/she began getting agitated. The resident was then taken to the supervisor office. -Progress note on 9/2/22 at 12:49 A.M., showed: The resident returned from ER with no new orders. Review of the POS, dated 9/6/22, showed: -Buspirone Hcl (a medication used to treat anxiety) 5 mg three times a day for anxiety, ordered 9/6/22; administer as ordered. The resident's record did not include details on why the medication was ordered or who ordered it. -Wanderguard (a bracelet and alarm system used to monitor when someone wearing the bracelet is close to a door or attempting to exit a door): check placement and function every shift, ordered 9/6/22. Review of the POS, dated 9/9/22, showed: -Depakote DR order increased to 375 mg three times a day. The diagnosis listed for treatment was agitation, however, there was no documentation to show the reason for the increase. Review of the resident's medical record dated 9/2/22 to 9/11/22 showed no documented behaviors, no exit seeking behaviors, and no aggression towards staff or other residents. Review of the residents medical record showed: -Progress notes, dated 9/12/22 at 11:08 A.M., the resident tested positive for COVID and placed in isolation unit. Review of the POS, dated 9/12/22, showed: -Zyprexa (an antipsychotic used to treat schizophrenia, bipolar disorder) 5mg every 8 hours for agitation/aggression, ordered 9/12/22, administered as ordered. The resident's record did not show documentation as to why the medication was ordered. Review of the manufacturer's guidelines for Zyprexa showed: - it is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder); - it may also be used in combination with other medication to treat depression; -side effects include drowsiness -elderly patients with dementia-related psychosis treated with olanzapine are at an increased risk of death compared to placebo. Zyprexa is not approved for the treatment of patients with dementia-related psychosis. Review of the resident's medical record, dated 9/13/22 at 1:51 A.M., showed: -The resident refused vital signs. Resident will not stay in his/her room and becomes agitated with staff when encouraging him/her to stay in his room. Resident tried to push past staff and was threatening. Nurse Practitioner called and order received to send to ER. He/she was given Zyprexa medication in the ER and returned to the facility. Returned at 11:58 P.M. He/she remains 1:1 and resting in his/her new room in isolation. Nurse practitioner called and order for Zyprexa received. Review of the resident's medical record, dated 9/13/22, showed no documentation to address the underlying causes of the distressed behavior; or any non-invasive individualized interventions prior to administering medications, or sending the resident to the hospital. Review of the resident's medical record, dated 9/14/22 to 10/7/22, showed no documented behaviors, no exit seeking behaviors, no aggression towards staff or other residents. Review of Behavior Intervention Monthly Flow Record showed: -No behaviors noted for September 2022; -No documentation of interventions to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the antipsychotic medication. Review of the POS, dated 10/7/22 to 10/21/22, showed: -Depakote DR order increased to 500mg three times a day ordered 10/7/22, administered as ordered. The resident's record did not contain documentation to support the use or increased dosage of the medication. Review of resident's medical record, dated 10/12/22 to 10/15/22, showed: -Progress notes dated 10/12/22 at 1:29 A.M., The resident was walking and pacing during later evening. Given Vistaril. He/she was sleeping most of this time. -Progress notes, dated 10/14/22 at 12:17 A.M., The resident was pacing the halls most of the evening. Vistaril given. -Progress notes, dated 10/15/22 to 10/21/22, showed no behaviors noted. -No documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions. Review of the POS dated 10/22/22 to 10/28/22 showed: - Ativan 0.25mg at 4 PM daily, ordered 10/21/22. The resident's record did not include documentation to support the use of the medications. The order was received verbally, however, there was no physician signature on the order. Review of the manufacturer's guidelines for Ativan showed: -Should be used with caution in elderly due to the risk of sedation and/or musculoskeletal weakness that can increase the risk of falls, with serious consequences in this population; -Elderly or debilitated patients may show a more sensitive response to the effects of Ativan; therefore, these patients should be more frequently monitored and given a reduced dose; -Side effects of sedation, drowsiness, dizziness, ataxia (impaired balance and coordination) Review of the medical records showed no documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the order of the Ativan on 10/21/22. Review of the resident's medical record, dated 10/22/22 to 10/27/22, showed no behaviors documented. Review of the resident's medical record, dated 10/28/22 at 11:47 P.M., showed: -The resident had increased pacing, given Vistaril as ordered. -No documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the Vistaril. Review of the resident's medical record showed no consultation with psychiatry or psychology to address the behaviors prior to the administration of the antipsychotic medications. No documentation of the resident or the administration of the antipsychotic medication in the weekly risk management meetings. Review of Behavior Intervention Monthly Flow Record showed: -Continuous pacing and striking out noted on October 25, 27, and 30, 2022; with intervention of medication. -No other interventions noted for times of pacing/striking out. -No documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the antipsychotic medication. Review of the resident's Medication Administration Record showed Vistaril was given without documentation to address the underlying causes of the distressed behavior or any non-invasive individualized interventions prior to the administration of the antipsychotic medication: -10/11/22 at 8:30 P.M. for anxiety, follow up showed resident was resting; -10/18/22 at 8:30 P.M. for anxiety, follow up showed resident was asleep; -10/25/22 at 7:30 P.M. no indication for use; -10/27/22 at 7:30 P.M. no indication for use, follow up showed resident was resting; -10/29/22 at 7:30 P.M. for anxiety; -10/30/22 at 7:30 P.M. for anxiety, follow up showed resident was resting; -10/31/22 at 1:30 P.M. for anxiety; Observations on 11/01/22 beginning at 8:44 A.M., showed: - Resident was lying in bed, on top of covers, head to the far left corner and feet toward the far right corner; one shoe off and one shoe on, snoring with mouth open, staff sitting at bedside. -At 10:54 A.M., the resident remained in bed in the same position and continued to snore with mouth open. -At 1:21 P.M., The resident was in bed, remained in same position, continued to snore with mouth open. -Staff sitting at bedside with no resident interaction. During an interview on 11/1/22 at 1:21 P.M., Certified Nurse Aide (CNA) F said: -Staff stay with the resident all the time. -He/she sleeps a lot and does not get up much. -He/she sleeps more in the last couple of weeks. -There have been no behaviors today; he/she has only slept today. -He/she was 1:1 for trying to leave. -Staff are to call the nurse if behaviors occur. -No other interventions, call nurse for assistance. Observation on 11/02/22 at 10:51 A.M., showed: -The resident was in bed, on his/her back. -One side half covered by sheet. -Staff sitting at bedside no with resident interaction. When asked about the resident still being in bed, staff replied he/she was sleeping in. Observation on 11/02/22 at 12:01 P.M., showed: -CNA D in room. -The resident was physically assisted to stand and sit in a bed side chair by CNA D. -The resident was having difficulty keeping eyes open when talking. -The resident's speech was slow and soft, words are slow and elongated during enunciation. -Resident's bottom sheet noted to have multiple and varying brown rings of dried urine. -CNA D assisted the resident to the restroom with fresh clothing. During an observation and interview on 11/02/22 at 12:09 P.M., showed: -The resident was in bed, lying on his/her back. -CNA D said: -The resident had not been up today. -The resident had been sleeping a lot recently. -He/she calls the nurse if behavior occurs. -There are no other interventions for behaviors, except calling the nurse. During an interview on 11/03/22 at 8:55 A.M., CNA G said: -The resident has never had behaviors with him/her. -If the resident starts patting his/her head staff need to back away, and give him/her some space. -The resident's behaviors are about how he/she was approached. -When staff introduce themselves and start kindly it all goes well, and he/she has no behaviors. -Staff can't tell him/her what to do, that does not work. -His/her family made this care plan (indicating the care plan on the wall) and it was very helpful, if it's used. -He/she would notify the nurse if behaviors occurred. During an interview on 11/03/22 at 9:21 A.M., Licensed Practical Nurse (LPN) E said: -If the resident has any behaviors the CNAs will yell for help. -When staff call for help, the resident is assessed and redirection is attempted by him/her. -Medication is administered if needed. -Only nurses can administer as needed medication. -If that doesn't work then the Police are called for assistance. -The resident only hit staff one time, early in his/her stay in the facility. -The resident had never been away from his/her family so it's very hard for him/her. -If the resident was having a bad day he/she calls the family. They have a very good relationship. Observation on 11/3/22 at 3:30 P.M., showed: -The resident was up walking in the hall. -Steps are slow and shuffling. -He/she answers questions with one word answers. -Resident requested to dance, then walked back to his/her room. During an interview on 11/03/22 at 3:46 PM the Social Service Director (SSD) said: -The resident was currently 1 on 1 with CNAs. -He/she did not have 1 on 1 visits with the resident. -He/she does rounds every morning to ensure the resident has his/her wanderguard bracelet on. -The resident was not seen by psychologist. -The resident had an order for a Psychiatry consult, then got COVID. -The resident has been seen by Psychiatry. -He/she was unsure why the Psychiatry notes aren't in the residents chart. -There are no other interventions to deal with the resident's behaviors besides those that are listed in the care plan. During an interview on 11/03/22 at 3:50 P.M., the Social Service Aide said: -He/she does not sit or visit with the resident. -He/she waves or says hello only. During an interview on 11/03/22 at 3:45 P.M., the Director of Nursing (DON) said: -He/she expects staff to follow the care plan for any resident specific needs prior to medication use. -He/she expects staff to notify the Charge Nurse to handle behaviors. -He/she expects staff to have ongoing training and education about behaviors and interventions. -Medications are ordered by the nurse practitioner or physician and adjusted as needed. During an interview on 11/03/22 at 4:05 P.M., the administrator said: -He/she expects staff to attempt redirection for behaviors. -He/she expects staff to notify the Charge Nurse of behaviors. -He/she expects the resident care plan to be followed. -Medications are adjusted after behavior meeting every week if needed. During an interview on 11/23/22 at 9:03 A.M., the facility Medical Director/Primary Care Physician (PCP) A said: -Behavior meetings are conducted every week, which includes discussions of behaviors and medications. He/she does attend these meetings. -He/she does not remember discussing this particular resident at the weekly meetings. -Zyprexa should not have been started without an approved diagnosis. -Agitation is not an approved diagnosis for use of Zyprexa. -Shuffling gait, slow speech and sleeping long amounts of time are considered extrapyramidal side effects (a group of symptoms that can occur in people taking antipsychotic medications which can include slower thought processes, slower movements, rigid muscles, difficulty speaking, feeling restless, or muscles to involuntarily contract and contort). -The use of antipsychotic medications with for a dementia diagnoses only is unacceptable. -Psychotropics should be added one at a time to determine the effectiveness of each medication. -He/she was not aware the resident was on all of the medications.