Failure to Attempt and Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented prior to the administration of PRN psychotropic medications for a resident with severe cognitive impairment and behavioral symptoms. The resident, who had diagnoses including dementia, delusional disorders, and depression, had a care plan that included non-pharmacological approaches such as reassurance, encouraging activities of choice, 1:1 visits, and redirection. Despite these care plan interventions, documentation showed that lorazepam was administered on multiple occasions for behavior issues or other reasons, but there was no evidence in the clinical record or behavior monitoring logs that non-pharmacological interventions were attempted before medication was given. The facility's records, including the Medication Administration Record and Target Behavior Monitoring logs, lacked documentation of target behavior episodes and management interventions for the relevant dates when the PRN psychotropic was administered. Interviews with the consulting pharmacist and the DON confirmed that non-pharmacological interventions should have been attempted and documented prior to administering PRN psychotropics, except in severe situations. The facility was unable to provide a policy regarding this practice when requested.