Health inspection·May 31, 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. Based on medical record review, staff interview, policy review, and review of the medication information from Medscape, the facility failed to ensure a resident was free from unnecessary psychotropic medication usages when the facility failed to have an adequate indication of use for an antipsychotic medication. This affected one (#132) out of three residents reviewed for psychotropic medication usage. Facility census was 129. Findings include: Review of the medical record for Resident #132 revealed an admission date of 05/03/23. Diagnoses include unspecified head injury, concussion, repeated falls, hypertensive chronic kidney disease, depression, and restless leg syndrome (RLS). The medical record revealed Resident #132 was discharged on 05/16/23. Review of the medical record for Resident #132 revealed an admission Minimum Data Set (MDS) 3.0, dated 05/10/23, which indicated Resident #132 had severe cognitive impairment and required limited assistance with bed mobility, toileting, and transfers. The MDS indicated Resident #132 received an antipsychotic medication routinely. Review of medical record for Resident #132 revealed a physician order dated 05/05/23 for haloperidol (antipsychotic medication) 10 milligram (mg) by mouth daily at bedtime routinely for agitation. Review of medical record for Resident #132 revealed a medication administration record (MAR) for May 2023 which revealed Resident #132 received haloperidol 10 mg daily at bedtime routinely from 05/06/23 to 05/16/23 for agitation. Review of the medical record for Resident #132 revealed a behavior monitoring assessment, dated 05/06/23 at 11:28 P.M., which stated Resident #132 was agitated, anxious, had continued pacing, fighting, restless and wandering. The assessment stated staff provided one on one supervision, changed positions, removed the resident from the environment, toileted resident, and redirected resident which were all ineffective. Further review of the assessment revealed the documentation was initiated on 05/06/23 but was not completed until 05/26/23. Review of the medical record for Resident #132 revealed a nursing progress note dated 05/06/23 at 11:28 P.M., which stated Resident #132 was ordered haloperidol 10 mg by mouth daily at bedtime routinely due to agitation. Page 1 of 2 366151 366151 05/31/2023 Dayspring of Miami Valley Hlth Care Center & Rehab 8001 Dayton Springfield Road Fairborn, OH 45324

F 0758 Level of Harm - Minimal harm or potential for actual harm Interview on 05/31/23 at 1:00 P.M. with Registered Nurse (RN) #335 stated she was the nurse who took care of Resident #132 on the evening of 05/05/23. RN #335 stated Resident #132 was very agitated, was attempting to elope and was hitting, kicking, and spitting staff. RN #335 confirmed Resident #132 did not have a diagnosis of schizophrenia, or a psychosis disorder and confirmed the haloperidol was ordered for Resident #132's agitation. Residents Affected - Few Review of facility policy titled Psychotropic: Anti-psychotic Medication Management, revised October 2017, stated residents who have not used psychotropic drugs are not to be given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy also stated if an anti-psychotic medication is ordered, an appropriate diagnosis will be assigned to the medication and behavior monitoring will be initiated. Review of medication information from Medscape at https://reference.medscape.com/drug/haldol-decanoate-haloperidol-342974, revealed haloperidol (Haldol) is an antipsychotic medication and is used for schizophrenia, psychosis and Tourette Disorder. Haldol has a Black Box Warnings which indicates patients with dementia-related psychosis who are treated with antipsychotic drugs are at an increased risk for death, as shown in short-term controlled trials; deaths in trials appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Haldol is not approved for treatment of patients with dementia-related psychosis This deficiency represents non-compliance investigated under Complaint Number OH00143160. 366151 Page 2 of 2