Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to administering a PRN psychotropic medication to a resident. The facility's policy on antipsychotic medication use requires that pertinent non-pharmacological interventions be attempted and documented unless contraindicated. However, the clinical record of a resident with diagnoses including anxiety, major depressive disorder, and cognitive communication deficit, showed multiple administrations of PRN Hydroxyzine for anxiety without documentation of attempted non-pharmacological interventions. The resident's Medication Administration Record indicated frequent use of PRN Hydroxyzine over December 2024 and January 2025, yet there was no evidence in the clinical record of non-pharmacological interventions being attempted before these administrations. During an interview, the Director of Nursing confirmed the absence of such documentation and acknowledged that non-pharmacological interventions should have been attempted and recorded in the clinical record.
Plan Of Correction
Resident (58) as well as all other residents will be free from unnecessary psychotropic medications. R(58)'s medication orders will be reviewed by physician to ensure applicable psychotropics are being administered. R(58)'s orders have been updated to implement non-pharmacological interventions before psychotropics are administered and will add supplemental documentation in the order. Director of Nursing/designee will educate nursing staff on what non-pharmacological interventions are and how to properly implement them before psychotropic medication is administered. All Residents on psychotropics will have orders for supplemental documentation that non-pharmacological interventions were administered before medication was given. All PRN psychotropic medications will be reviewed by the assistant director of nursing/designee to ensure that the non-pharmacological interventions are being completed once daily for five (5) days times two (2) weeks, once weekly times two (2) weeks, once monthly times two (2) months and ongoing after that to ensure compliance. Results will be brought to monthly Quality Assurance meetings to audit progress and address any ongoing concerns.