Failure to Document Indication and Monitor Use of Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, psychoactive substance dependence, and Parkinson’s Disease was administered Ativan (Lorazepam), a psychotropic medication, without a clearly documented indication for its use. The resident was cognitively moderately impaired and dependent on all activities of daily living, with impairments in both upper and lower extremities. The care plan specified the use of anti-anxiety medication as needed for anxiety manifested by restlessness and agitation, but the specific manifestations were not consistently documented in the medication administration records or progress notes. Review of the Medication Administration Record showed that Ativan was given on multiple occasions for exhibiting a behavior, but the exact manifestation or behavior warranting the medication was not specified. The order summary for Ativan indicated it was to be given as needed for anxiety manifested by certain behaviors, but the manifestation was not clearly documented. Interviews with nursing staff confirmed that the order was incomplete, missing the required manifestation, and that monitoring of the resident’s behavior and side effects was not consistently documented as required by facility policy. Facility policies required that PRN psychotropic medication orders specify the condition for administration and that adequate indications for use be documented, including ongoing monitoring of mood, behavior, and side effects. The lack of clear documentation regarding the indication for Ativan administration and insufficient monitoring of the resident’s response and side effects led to the deficiency, as the facility failed to ensure that the use of psychotropic medication was appropriate and properly monitored for this resident.