**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Nurse Practitioner, and Pharmacy Clinical Director interviews, the facility failed to have a documented diagnosis for the use of an antipsychotic medication (Seroquel/quetiapine) for 1 of 5 residents reviewed for unnecessary medications (Resident #54). The findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included anxiety and hypertension. Review of Resident #54's care plan initiated on 12/02/24 revealed she had a care plan for the use of psychotropic medications. A physician order dated 12/02/24 read; quetiapine (an antipsychotic medication) 25mg - give 1 tablet at bedtime. The order was discontinued on 12/08/24. A physician progress note dated 12/08/24 written by Nurse Practitioner #1 read in part; Patient is requesting scheduled extra strength [acetaminophen] for chronic back pain. She is also requesting something more for insomnia. Seroquel (quetiapine) increased . A physician order dated 12/08/24 read; quetiapine 50mg - give 1 tablet at bedtime. The order was discontinued on 12/16/24. Review of Resident #54's admission Minimum Data Set assessment dated [DATE] revealed Resident #54 was cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. Resident #54 was coded as taking antipsychotic medication on a routine basis, a gradual dose reduction had not been attempted and was not clinically contraindicated. A physician progress note dated 12/16/24 written by Nurse Practitioner #2 read in part: Patient reports she is feeling great today. She denies any increase dyspnea or cough. She reports difficulty with sleep since previous admission. Seroquel increased. A physician order dated 12/16/24 read; quetiapine 100mg - give 1 tablet at bedtime. An interview with Nurse #1 on 01/09/25 at 8:55 AM revealed she was familiar with Resident #54 and reported she was aware that she was receiving scheduled quetiapine and stated she was being monitored for potential side effects of the medication. Nurse #1 indicated that she did not see a psychological condition listed in Resident #54's diagnoses that would indicate a reason for her to take quetiapine but reported she was aware that some of the physicians in the hospital used it as a sleep aide. Nurse #1 indicated it appeared as though Resident #54 was being prescribed quetiapine as a sleep aide. An interview with Nurse Practitioner #1 on 01/09/24 at 09:06 AM revealed she was familiar with Resident #54 and stated she was also aware Resident #54 was prescribed a scheduled dose of quetiapine. Nurse Practitioner #1 revealed she believed that Resident #54 had been taking the quetiapine at home prior to her admission to the hospital as a sleep aide. Nurse Practitioner #1 stated she would not typically use quetiapine as a sleep aide but since Resident #54 had admitted to the facility already taking it for help with sleep, she just continued it. She continued, stating that typically, when a resident transitioned from the acute care side of the hospital to the long-term care side, the pharmacy staff reviewed the resident's medications and would flag any medications that did not have supporting diagnoses for so they can be discontinued, or the resident could be reevaluated for a supporting diagnosis. She stated based on the records she could see in her charting system; it did not appear as though the pharmacy had sent that initial medication review to her with the quetiapine flagged for not having a supporting diagnosis. Nurse Practitioner #1 indicated there did not appear to be an appropriate supporting diagnosis for the continued use of Resident #54's quetiapine. An interview with Pharmacy Clinical Director on 01/09/24 at 11:02 AM revealed that when a resident transitions from acute care to long-term care, they reviewed their medications and flagged any medications that did not have supporting diagnoses so the clinicians could adjust, discontinue, or reevaluate the residents. She stated according to her records, a review was completed on 12/03/24 and they flagged Resident #54's quetiapine for not having a supporting diagnosis. She reported her records indicated the alert was emailed to Nurse Practitioner #1. She stated once they flag the medication, they have no follow-up procedures to ensure the recommendation was addressed and stated if it was not addressed, they would not know until the following monthly medication review was completed. An interview with the Director of Nursing on 01/09/24 at 12:52 PM revealed she was aware of federal regulation that required appropriate diagnoses for the use of antipsychotic medications and the hospital would occasionally prescribe quetiapine as a sleep aide. She also reported most of the time, the residents admitted to her unit were only there for a very short period and so they continue the medications they were admitted with. She stated the pharmacy usually notified them, along with the physicians, when there was a lack of a supporting diagnosis for the use of antipsychotics. She stated if the facility would be notified that there was a lack of a supporting diagnosis for the use of antipsychotics, it would be solely up to the attending physicians to address the discrepancy. The Director of Nursing indicated she was unsure whether the initial medication review occurred and reported the lack of a supporting diagnosis should have been caught by pharmacy and or the physician and addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, Assistant Director of Dialysis and Medical Director interview, the facility failed to monitor and assess the right subclavian catheter (temporary or permanent, simple, tunneled, or connected to a port under the skin to provide dialysis treatment) and the left arteriovenous dialysis fistula (AVF is a fistula created between an artery and a vein to provide dialysis treatments) for a resident receiving hemodialysis for 1 of 1 sampled resident (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE] with a diagnosis of renal insufficiency and treatment with renal dialysis. A review of the physician orders dated 7/19/23 stated that hemodialysis on Monday, Wednesday, and Friday, and for dialysis nurse to change dialysate based on morning Potassium levels. A review of the most recent care plan last updated 7/20/23 indicated scheduled dialysis treatments on Monday, Wednesday, and Fridays. The interventions were to provide dialysis treatments as scheduled, monitor abdomen for signs of infection, daily weights, and evaluate access sites for signs of infection. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no cognitive impairment with memory problem. The resident was coded as limited assistance for bed mobility and required extensive assistance with activities of daily living. An undated document titled, Dialysis training (a document used by nurses that explained all possible sites, assessments, adverse reactions, and when to contact the doctor), specified to check the bruit and thrill (a thrill was a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above your incision line. A bruit was the whooshing sound while auscultating with a stethoscope) daily and to notify patient nephrologist immediately with decreased or absent. Record review of Resident #7's electronic record, the medical chart, nursing notes, and spreadsheets revealed no documentation or evidence of the monitoring of the right subclavian catheter and the left arteriovenous dialysis fistula by the facility nursing staff. An interview on 10/26/23 at 9:00AM with Nurse #1 stated she was not tasked to check the dialysis accesses. She had never had an order or task to check an AVF or a subclavian catheter. She stated that the bruit and thrill was checked by dialysis. She revealed she had training on the dialysis site assessment when she was hired and was aware to check the condition of the dialysis access (s). She stated the required task appeared on the chart to complete. Tasks that do not appear on the task list, do not get completed. Nurse #1 reported she was routinely assigned to Resident #7. An interview on 10/26/23 at 4:00PM Director of Nursing stated the nurse should check the thrill and bruit of the AVF or the subclavian catheter at least once a day and document in the medical record. An interview 10/27/23 at 9:00AM Assistant Director (AD) of the dialysis unit indicated the standard of care after dialysis was to monitor access(s) for bleeding, swelling, and patency. The dialysis nursing staff or physician were contacted after treatments, with any bleeding or change to the access site. An interview with the Medical Director on 10/27/23 at 11:16AM revealed the nursing staff assessed every resident who received dialysis. Check the bruit and thrill at least daily a complete set of vital signs and monitor for any signs of infection every shift.