Health inspection·March 17, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify an appropriate indication for administration of an antipsychotic medication for two residents with a diagnosis of Dementia (R31, R42) of three residents reviewed for unnecessary antipsychotic medications in the sample of 18. Findings include: Facility Policy/Psychotropic Medication dated/revised 11/28/17 documents: These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the medical record. Specific condition/medical symptoms alone are not enough to justify pharmalogical use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. Additionally, antipsychotic medication may be indicated for use if: Behavioral symptoms present a danger to the resident or others; Expressions or indications of distress that are significant distress to the resident. 1) Physician's Order Summary Report indicates R31 was admitted to the facility 12/31/19 with diagnoses that include Chronic Post Traumatic Stress Disorder, Unspecified Dementia - Unspecified Severity with Other Behavioral Disturbance, Moderate Recurrent Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Unspecified Macular Degeneration. Report indicates Seroquel (antipsychotic) 25mg (milligrams) at bedtime related to Chronic Post-Traumatic Stress Disorder was initially ordered on 1/19/23. MAR (Medication Administration Record) indicates R31 continued to receive Seroquel through 3/15/23. Pre admission Screening dated 1/4/20 indicates R31 was admitted without mental illness or developmental disability. Antipsychotic Medication Consent indicates consent was received to administer Seroquel 25mg for Post-Traumatic Stress Disorder on 1/18/23. Consent indicates medication is used to treat specific conditions, such as Schizophrenia, Delusional Disorder, Schizoaffective Disorder, Acute Psychotic Episodes, Atypical Psychosis, Tourette's Disorder, Huntington's Chorea, Psychotic Mood Disorder, Manic Behavior. Behavior Note dated 1/31/2023 at 7:29pm indicates peer talking on her cell phone propelling herself Page 1 of 3 146063 146063 03/17/2023 Allure of Walnut 308 South Second Street Walnut, IL 61376

F 0758 Level of Harm - Minimal harm or potential for actual harm down the hallway when above resident R31 started yelling at peer and grabbed the arm of the wheelchair and stopped peer from going on any further - yelling at peer that she should not be talking on the phone and continued to yell at peer. Staff separated R31 from peer, then R31 again wheeled toward peer and grabbed the wheel of her wheelchair and prevented peer from going any further - again residents separated with R31 brought to day room completely away from peer. Residents Affected - Few Behavior Note dated 2/14/23 at 8:57pm indicates R31 was agitated and rude to peer. Note indicates R31 and peer separated No further behaviors noted. Behavior Note dated 3/9/23 at 6:34pm indicates R31 agitated with staff, threatening to hit nurse because no one was helping her; told nurse and another staff to stop talking and take care of her. Note indicates R31 did go to her room, put on call light and was pleasant as shift progressed. CNA (Certified Nurse Assistant) Behavior Monitoring and Interventions Report dated 1/1/23 to 3/15/23 indicates R31 had the following behaviors: 3/9/23 threatening others. No other behaviors identified between 1/1/23 and 3/15/23. Current Comprehensive assessment dated [DATE] indicates R31 had no hallucinations, delusions, wandering or behavior symptoms and behavior is Improved. Current Care Plan indicates R31 has a behavior problem related to diagnosis of dementia; R31 can curse, yell, push and have repetitive movements. Care Plan indicates R31 can be rude and verbally abusive to staff, residents and visitors; can be difficult to redirect. Current Care Plan also indicates R31 receives an antipsychotic for her PTSD (Post Traumatic Stress Disorder) related to tragically losing a son within the last couple of years that R31 witnessed. Care Plan indicates R31 thinks about her son and the accident throughout the day and is angry at GOD for letting this happen. Psych Services Note dated 1/18/23 and 3/15/23 indicate R31 has no Abnormal/Psychotic/Perceptual Disturbances. Note indicates Behavior is Within Normal Limits. On 3/16/23 at 1:00pm V5, MDS (Minimum Data Set) Coordinator stated R31 didn't talk about losing her son unless she was asked about it directly. V5 stated that she questioned the psychiatric services order for Seroquel for R31 but She's the physician and felt she couldn't question the order for the antipsychotic medication any further. V5 stated that they now have orders to reduce and then discontinue the Seroquel. 2) R42's medical record documents R42 admitted to the facility on [DATE]. R42's medical record dated 1/6/23 documents a diagnosis of unspecified dementia, unspecified severity with agitation. R42's physician visit with V9, Medical Doctor (MD), dated 12/28/22 documents Primary Diagnosis: Severe dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, unspecified dementia type. 146063 Page 2 of 3 146063 03/17/2023 Allure of Walnut 308 South Second Street Walnut, IL 61376

F 0758 R42's medical record does not include a diagnosis of psychosis prior to 1/18/23. Level of Harm - Minimal harm or potential for actual harm R42's behavior tracking dated 1/7/23 at 7:31 PM documents Behaviors: noted agitation and hitting staff in the dining room. verbally threatening others. redirected. reassured. one on one. calmed down. seems to dislike crowds of people. will talk to self. very confused. orientated only to self. Residents Affected - Few R42's behavior tracking dated 1/8/23 at 6:06 PM documents Behaviors: Wandering: exit seeking. verbally abusive to staff. redirected. reassured. R42's progress notes dated 1/9/23 at 8:47 PM documents Resident alert and oriented to person, expressed agitation and wandering this evening, along with exit seeking and hitting CNA (Certified Nursing Assistant). Resident was unable to be redirected. Resident thought that staff were wearing masks to hide something. Resident has hallucinations and carried on conversations with those hallucinations. R42's progress notes dated 1/10/23 at 8:18 PM documents Resident alert and oriented to person, wandering halls, and having hallucinations. Resident will talk to hallucinations as if real, no pain or shortness of breath noted at this time, will continue to monitor. R42's physician order dated 1/10/23 by V9, MD, documents Haloperidol (Haldol) Tablet 5.0 milligrams (mg). Give 5.0 mg by mouth every 24 hours as needed for agitation and restlessness. R42's physician order sheet dated 1/10/23 and ordered by V9, MD, documents Haloperidol Tablet 5.0 mg. Give 5.0 mg by mouth every 24 hours as needed for agitation and restlessness. R42's antipsychotic consent form dated 1/10/23 documents Haloperidol 5.0 mg every 24 hours as needed for agitation and restlessness. R42's medication administration record dated January 2023 documents R42 received Haldol 5.0 mg on 1/12/23 and 1/13/23. R42's medical record documents R42's initial psychiatric assessment by V7, Psychiatric Nurse Practitioner (NP), was conducted on 1/18/23. On 03/15/23 at 11:04 AM, V6, Medical Director, stated I've never seen anyone develop psychosis late in life. You don't develop psychosis at [AGE] years old outside of drug induced psychosis which he (R42)doesn't have. He shouldn't have the unspecified psychosis not due to a substance or known physiological condition diagnosis. I agree with what you're saying, (R42) has no history of psychosis and all of his behaviors can be associated with dementia. So I agree with you that his symptoms and behaviors can be from dementia. On 3/17/23 at 9:50 AM, V8, Regional Nurse Consultant, verified R42 did not have a diagnosis of psychosis prior to being administered an antipsychotic medication and stated The order came from his outside personal physician (V9, MD). It didn't come from the medical director (V6, MD) or our psychiatric provider (V7, NP). (V7, NP) didn't evaluate (R42) until 1/18/23. What happened is that the nurse called his personal physician due to his behaviors and they ordered the Haldol and no one questioned the order. No, they didn't try any other medications for his behaviors prior to giving him the Haldol. 146063 Page 3 of 3