Failure to Limit PRN Psychotropic Medication and Attempt Non-Pharmacological Interventions
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure a resident was free from chemical restraints. Specifically, a resident was prescribed PRN Ativan orders that extended beyond the 14-day limit without documented physician or practitioner review and rationale for continuation. The resident received multiple PRN Ativan orders, each lasting longer than 14 days, and there was no evidence that these orders were appropriately reviewed or justified as required. Additionally, the facility did not attempt or document non-pharmacological interventions prior to administering PRN Ativan on several occasions, despite the resident's care plan indicating that such interventions should be attempted for mood and behavior concerns. The Medication Administration Record did not track these interventions, and progress notes only documented the administration of medication in response to symptoms such as anxiety or psychosis, without reference to non-pharmacological measures. The DON confirmed the lack of documentation and acknowledged that non-pharmacological interventions were not attempted or recorded as required.