F-Tag 757, freedom from unnecessary drugs, and F-Tag 758, freedom from unnecessary psychotropic medications, are closely affiliated and are often cited together during a survey. Regulation 758 defines a psychotropic medication as one that affects the brain with mental processes and behaviors.
These medications fall into one of 4 categories:
- Anti-psychotic
- Anti-depressant
- Anti-anxiety
- Hypnotic
Use of anti-psychotic medications requires participation from multiple levels of staff and consultants before the administration can begin.
Decision makers include, but are not limited to:
- The resident’s PCP
- The medical director
- The consultant pharmacist
- The administrator
- The director of nursing
- The MDS nurse
- The clinical staff
Medication administration and follow up must be thoroughly documented by the clinical staff to remain in accordance with regulation standards.
Since November 2017, statistics show that citations for F-Tag 757 and 758 have increased under the new regulations, and require more concentration. F-Tag 757 was cited with the highest scope and severity, identified as level J, 225 times in 32 states within a 6-month time frame. F-Tag 758 was cited with the highest scope and severity, identified as level E, 426 times in 43 states within a 6-month time frame.
The top five states receiving deficiencies are:
- California
- Texas
- Ohio
- Florida
- Indiana
These five states received 124 citations collectively.
Most cited states include:
- California
- Ohio
- Washington
- Illinois
- Michigan
- Missouri
These states collectively received 166 of the total 426 citations.
A full assessment, substantiating the need to administer psychotropic medication to a specific resident, is required. It is critical that policies are in place regarding matters under the facilities QAPI plan before supplying the script to the medical admitting resident (MAR).
Questions for the QAPI plan include:
- What is the clinical diagnosis that would require this medication?
- Has there been sufficient research on the potential interactions with other medications the resident is currently taking?
- Has the consultant pharmacist and the primary care physician (PCP) identified any treatment or medication that could be utilized in place of antipsychotic medication?
- Has the consultant pharmacist and the PCP reviewed the duration, monitoring parameters, adverse risks, and any urgent actions needed regarding the medication?
Documentation and pre-planning are essential steps to consider under F-Tag 758. These practices help protect residents and your facility from receiving citations.
Questions to ask before the implementation of psychotropic medication:
- Are current policies in place identifying the use of psychotropic medications?
- Has the policy been reviewed and updated regarding how to address medication errors with the use of psychotropic medications?
- Has the use of psychotropic medications been identified on the facility assessment and reviewed in the QAPI program?
- Has a monitoring program been established after initiation of a new medication such as a psychotropic drug?
- Is there a clear and documented diagnosis for the medication requested?
- Have the PCP and medical director been updated on the request for the medication, as well as given a list of the resident’s current medications for possible adverse interactions? Adverse interactions could include but are not limited to:
- General – flushing of skin, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation, constipation
- Cardiovascular – signs or symptoms of cardiac arrhythmia, palpitations, light headedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, orthostatic hypotension
- Metabolic – increase in total cholesterol and triglycerides, unstable blood sugars, weight gain
- Neurologic – agitation, distress, EPS (Extrapyramidal Symptoms), parkinsonism, tardive dyskinesia, CVA, or TIA
- Have the potential adverse indications been discussed with the resident, PCP and Medical Director?
- If a psychotropic medication is being used, are there sufficient and competent staff to administer and document outcomes on a 24-hour basis?
If the use of a psychotropic medication is warranted, it is the facilities responsibility to identify a possible gradual dose reduction (GDR). The pharmacy, pharmacy consultant, PCP, and Medical Director should all be involved in the process. Medications should be reviewed during the monthly medication regimen review (MRR), monthly visits by the PCP, or the quarterly MDS review.
There are residents for whom a GDR may not be advised, such as those receiving medication for distress related to dementia. In these cases, the physician must clearly indicate through clinical rationale that attempting dose reductions would likely impair the resident’s function or increase the distressed behavior.
This regulation can also be linked to other regulations as potential tags. See the table below:
| F-Tag | Description |
| F 580 | Failure to notify physician of changes related to potential adverse reactions. |
| F 552 | Not informing the resident of the use and potential side effects of the medication to allow for refusal. |
| F 679 | Does the facility provide other activities which would permit the reduction or discontinued use of a medication? |
| F 679 | Does the use of these medications interfere with the resident’s ability to participate in activities of their choice? |
| F 676 | Has the facility responded to any new or increased decline of the resident since initiation of the medication? |
| F 710 | Has the physician supervised the medical condition of the resident related to the use of these medications? |
| F 711 | Has the physician reviewed the total program of care, noted, signed and dated notes of the aspects of the medication regime? |
| F 841 | Has the medical director interacted with the physician regarding medication irregularities or failure of the physician to respond to any side effects. Has the medical director been involved in the development of policies for effective use of these medications? |
Planning and attention to detail are required when the administration of psychotropic medications is recommended. Absence of applicable policies could cause harm to residents and your facility.
