Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were documented and attempted prior to administering PRN anti-anxiety medications for two residents. For one resident with diagnoses including major depressive disorder, anxiety, psychotic disorder, dementia, and Parkinson's disease, records showed that Ativan was administered on two occasions without any documentation of non-pharmacological interventions being attempted beforehand. The care plan indicated the use of anti-anxiety medication as needed, but there was no evidence in the medication administration record that alternatives were tried prior to medication administration. The Director of Nursing confirmed that such documentation should have been completed. For another resident with a history of stroke, dementia, psychotic disorder, and other conditions, Lorazepam was administered multiple times for behaviors such as yelling, rambling, and increased anxiety. On each occasion, there was no documentation that non-pharmacological interventions were attempted before giving the medication. Staff interviews confirmed that interventions such as offering food, changing position, or checking for incontinence were expected prior to medication administration, but these were not documented. The facility's policy required that alternatives to psychotropic medication be incorporated into the care plan, but this was not reflected in the records reviewed.