Failure to Limit and Monitor PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that a resident was free from chemical restraints. Specifically, the facility did not provide non-pharmacological interventions before administering a prn (as needed) psychotropic medication, Ativan, to a resident with diagnoses including vascular dementia without behavioral disturbances, anxiety disorder, and depression. The resident had severely impaired cognitive skills and was dependent on staff for multiple activities of daily living. The care plan for the resident required non-pharmacological interventions prior to the use of Ativan, but this was not followed. Record reviews and staff interviews confirmed that the order for Ativan 1 mg every six hours as needed for restlessness was active and had been in place for more than 14 days, exceeding the facility's policy limit for prn psychotropic medications. Licensed nurses did not document the use of non-pharmacological interventions before administering Ativan, and the order was not reevaluated or renewed by a physician after 14 days as required. Staff acknowledged that Ativan was administered without first attempting less restrictive measures and without timely physician review. The facility's policy stated that prn orders for psychotropic medications are limited to 14 days and that non-pharmacological approaches should be used to minimize medication use. Despite this, the resident received Ativan beyond the policy limit and without documented attempts at alternative interventions, as confirmed by the Director of Nursing and other staff during interviews and record reviews.