Failure to Justify PRN Ativan Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. Specifically, Resident 12 was prescribed Ativan in various dosages, including routine and PRN (as needed) orders, which could result in the resident receiving up to 9 mg of Ativan in a 24-hour period. Despite the high potential dosage, there was no documentation justifying the need for the PRN Ativan, nor were non-pharmacological interventions attempted prior to administering the PRN doses. Clinical records and staff interviews revealed that Resident 12 exhibited behaviors such as rambling, restlessness, and chanting, but there was no significant change in her condition noted by her physician. The hospice social worker and staff documented instances of restlessness and anxiety, yet the facility's antianxiety monitoring did not reflect any noted anxiety or anxiousness. Despite this, PRN Ativan was administered multiple times without documented justification or attempts at non-medicinal interventions. The facility's pharmacy medication regimen reviews for November and December 2024 did not address the PRN Ativan order or request a physician review for a potential gradual dose reduction. This oversight was discussed with the Director of Nursing, highlighting a failure in the facility's processes to ensure appropriate medication management and documentation for Resident 12.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 12's physician reviewed Ativan orders. 2. All residents with PRN Ativan orders written for greater than 14 days were reviewed to confirm appropriate documentation, timeframe, and dosing. 3. Consultant pharmacist will review regulation on gradual dose reductions and limitations for timeframes of PRN Ativan use. 4. Audits of new PRN Ativan orders documentation, timeframes and total dose ordered will be completed weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.