Failure to Prevent Chemical Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of lorazepam gel without documented medical symptoms or behaviors that warranted its use. The resident, who was admitted with vascular dementia with behavioral disturbance and anxiety disorder, was prescribed lorazepam gel to be applied topically, despite having no contraindications for oral medications. The facility's policy required documentation of less restrictive alternatives and ongoing re-evaluation of the need for restraints, which was not provided in this case. The resident's clinical record showed multiple instances where the as-needed lorazepam gel was administered without supporting documentation of increased anxiety or behaviors. Observations revealed the resident was often groggy and not easily arousable, suggesting the medication was not used for a specific medical condition. Interviews with staff indicated the resident was usually groggy until midday, and the facility failed to provide evidence of attempts to address potential underlying causes of the resident's behavior. The facility's policy on medication regimen review required a prescriber to document the rationale for extending a PRN order past 14 days, which was not done. The Director of Nursing confirmed the lack of documentation for the resident's inability to tolerate oral medications and the absence of symptoms justifying the PRN medication. This lack of documentation and assessment led to the classification of the lorazepam gel as a chemical restraint, violating the resident's rights to be free from such restraints.
Plan Of Correction
Facility cannot retroactively correct deficiency. Resident 1's Ativan Gel was discontinued after review from the physician on 4/29/2025. PRN Ativan was ordered by physician beginning 4/30/2025 while facility completes a seven-day tracker of behaviors. Behavior monitoring ordered at the time of the new PRN medication. Care plan updated to reflect current orders. Current residents reviewed for PRN medications, behavioral monitoring and physician assessments with no corrections required. Education provided to physician assistant and medical director regarding PRN medication orders and required assessment of medication. Education provided to nursing staff on behavior documentation and use of non-pharmacological interventions prior to PRN usage. DON/designee will audit daily order summaries for PRN medications and examine use of PRN medications to ensure the regulations for PRN medications are followed X 2 weeks, then monthly X 2 months. Results to be forwarded to QAPI committee to ensure compliance.