Health inspection·March 5, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review of resident records, interview, and review of facility policy, the facility failed to obtain consent for 1 of 2 psychotropic medications ordered for 1 of 3 residents reviewed for psychotropic medication usage. (Resident #3) The findings included: On 3/4/24, a review of the records for Resident #3 was conducted. A review of the Medication Administration Record in December 2024 indicated that, in addition to Mirtazapine (an antidepressant) 30 mg once a day, Resident #3 had been taking Trazadone (another antidepressant) 50 mg .5 tablet every 8 hours. Resident #3's record had a signed consent to take Mirtazapine 30 mg once a day. However, there was no consent for the Trazadone. A review of the psychiatric notes, dated 9/26/24, for Resident #3 was conducted. The psychiatry notes stated that Resident #3 was started on Trazodone due to an exacerbation of depression and mood disorder. The note indicated that medication changes were needed to stabilize his symptoms. The provider indicated that risks, benefits, and alternatives were discussed. The note does not clarify whom the risks, benefits, and alternatives were discussed and if consent was verbally obtained from the resident's representative. Trazodone 25 mg po three times a day was instantiated in addition to the Mirtazapine for agitation. A review of the psychiatric notes dated 11/21/2024 revealed, Prior to last visit, resident had excessive sedation and was not wanting to eat. Trazodone 25 mg three times a day (TID) as needed (PRN) was started for 30 days. Trazodone 25 mg by mouth three times a day was discontinued as per the patient representative request. There was no note indicating that risks, benefits, or consent was obtained when the Trazadone dosing was changed from three times a day (TID) to three times a day as needed (PRN). A review of the orders was conducted for Resident #3. An order was placed on 9/27/24 for Trazodone 25 mg by mouth three times a day for major depressive disorder. The order end date was on 10/17/24. On 10/17/24, there was an order for Trazodone 25 mg to be given by mouth every 8 hours as needed for major depressive disorder for 30 days. The order end date was 11/17/24. There was also an order for Trazodone 50 mg half a tablet by mouth every 8 hours for major depressive disorder, start date 11/23/24 and end date 12/4/24. On 12/2/24, there was an order to hold the medication until further notice. A note entered with the order indicated that the medication needed to be discontinued. The order and note was written by the medical provider. Page 1 of 2 105433 105433 03/05/2025 Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/5/25 at 2:50 PM an interview was conducted with the Director of Nursing (DON). She was asked for a copy of the consent for the resident's Trazodone. The DON indicated that consent was not needed for Trazodone because it was an antidepressant. Although the facility had a consent for the Mirtazapine 30 mg once a day for depression, the DON reiterated that a consent was not needed for antidepressants. On 3/6/25 at approximately 9:30 AM, an interview conducted with the facility psychiatric nurse practitioner provider, who provided psychiatric services to Resident #3. She was informed about concerns regarding finding no consent for the Trazadone in the patients record. A consent for Mirtazapine was in the record of Resident #3, but not the Trazadone. The nurse practitioner indicated that she remembered the client and she explained the risks and the benefits of the medication Resident #3's representative before the Trazodone was initiated. The nurse practitioner indicated that the Trazadone was an antidepressant and therefore a psychotropic medication just like the Mirtazapine. On 3/6/25, a review of the facility policy and procedure titled Medication Management Psychotropic Medications, dated 10/24/2022, was conducted. The procedure section of the policy stated that residents receiving psychotropic medications will have the risk/benefits reviewed and consent completed prior to initiation of the medication. The policy further indicated that as needed (PRN) orders for psychotropic medications were to be limited for 14 days except when the prescribing practitioner believes that is appropriate to extend the medication beyond 14 days and documented the rationale and indicates the duration of the prn medication. 105433 Page 2 of 2