Failure to Document Indications and Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that as-needed anti-anxiety medication was administered with appropriate indications and that non-pharmacological interventions were attempted prior to medication administration for one resident. Review of the facility's undated Medication Management policy indicated that non-pharmacological interventions, such as behavior modification or social services, should be documented and utilized as part of the care planning process, and that the clinical record must reflect an adequate indication for the use of psychotropic medications. For one resident, a physician's order authorized as-needed Clonazepam for anxiety, but the Medication Administration Record showed that from May 9 to May 22, 2025, the medication was given ten times without documented indications and seven times without attempts at non-pharmacological interventions. The DON confirmed that the medication was administered without proper indication and without prior non-pharmacological interventions.