Failure to Document Nonpharmacological Interventions Prior to Psychotropic Medication Administration
Penalty
Summary
A deficiency was identified when a resident was administered temazepam, a sedative medication, for insomnia without documented evidence that nonpharmacological interventions were attempted prior to its use. The facility's policy requires that such interventions be implemented unless clinically contraindicated, and that psychotropic medications should only be used to treat medical symptoms, not for staff convenience or discipline. The resident's care plan specifically included interventions to address potential environmental and behavioral causes of insomnia before initiating hypnotic therapy, as well as the use of nonpharmacological approaches to improve sleep. Medical record review showed that the resident had ongoing orders for temazepam and monitoring for side effects, as well as instructions to document hours of sleep and to evaluate other factors contributing to insomnia. However, the Medication Administration Record (MAR) for the relevant period did not contain documentation that nonpharmacological interventions were provided prior to administering temazepam. The MAR included chart codes and prompt legends, but there was no indication that these interventions were attempted or documented, and the progress notes also lacked this information. During an interview, a registered nurse was unable to explain the meaning of certain chart markings related to nonpharmacological interventions and could not provide documentation that such interventions were implemented before administering the medication. This failure to document or implement required nonpharmacological interventions prior to the use of a psychotropic medication constituted a violation of the resident's right to be free from unnecessary chemical restraints.
Plan Of Correction
F605 - Right to be free from chemical restraint. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The facility will ensure that non-pharmacological interventions will be attempted prior to administration of hypnotic medication. For resident 1, documentation of non-pharmacological interventions used will be documented in the medication administration record (MAR) starting on 6/17/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. An audit of residents using hypnotic medication was completed on 7/2/25. No other resident uses hypnotic medication. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. The medical records department/designee will audit the medical records of the residents on hypnotic medication weekly to identify if non-pharmacological interventions were provided prior to administration. Findings will be reported to DON for follow-up. Inservice to licensed nurses initiated on 6/23/25 regarding psychotropic medication including providing non-pharmacological interventions. Completion date by 7/10/25. How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/10/25