Failure to Attempt Non-Pharmacological Interventions Before PRN Psychotropic 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. According to the facility's Psychotropic Medication Policy, non-pharmacological interventions and gradual dose reductions should be implemented unless contraindicated before starting or continuing psychotropic medications. However, review of the clinical record for a resident with diagnoses including osteomyelitis, anxiety, and anemia showed that Lorazepam was administered on four occasions in May 2025 without documentation of any non-pharmacological interventions being attempted beforehand. The Medication Administration Record confirmed the use of PRN Lorazepam on specific dates, and the clinical record lacked evidence of alternative interventions prior to each administration. During an interview, the Director of Nursing acknowledged that the clinical record did not contain documentation of non-pharmacological interventions before giving the PRN psychotropic medication, as required by facility policy.