Insufficient Documentation for PRN Injectable Antipsychotic Administration
Penalty
Summary
A resident with severe cognitive impairment and worsening behavioral symptoms, including verbal and physical aggression, was administered an as-needed injectable antipsychotic (Haldol) without sufficient documentation to justify its use for a specific medical symptom. The resident had a history of agitation, combative behaviors, and was recently seen in the emergency room for confusion and delirium, where an oral antipsychotic was given and an order for injectable Haldol as needed was prescribed upon discharge. Facility records showed the injectable antipsychotic was administered, but the behavior documentation at the time did not indicate a clear medical necessity for its use. Interviews with facility staff, including the Resident Care Manager and Director of Nursing, confirmed that as-needed antipsychotic medications should be limited, require adequate diagnosis, and must be supported by detailed documentation in the medical record. Review of the resident's records revealed poor documentation and insufficient justification for the administration of the injectable antipsychotic, which was acknowledged by facility leadership as not meeting the required standards for use.