Failure to Prevent Unnecessary Use of Psychotropic Medication as Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraint when Ativan, a psychotropic medication, was administered prior to off-site dialysis treatments without adequate assessment or documentation of need. The medication was prescribed following a single report of the resident being 'figgity' and pulling at his dialysis port, but there were no further documented incidents of negative behaviors or agitation. Despite this, Ativan was ordered and administered three times weekly before dialysis appointments for several months. Interviews with facility staff, including the Memory Care Director and Assistant Director of Nursing, revealed that no behavioral assessments were completed prior to the initiation of Ativan, nor were there follow-up assessments to monitor the resident's response or potential side effects. The Psychiatric Nurse Practitioner prescribed the medication based on a request from the Director of Nursing, who had been informed by the dialysis center of the resident's agitation. However, the only documented behavioral incident was from several weeks prior, and subsequent observations showed the resident to be alert, well-groomed, and without negative behaviors. The dialysis center later reported that the resident was arriving lethargic and that the responsible party was unaware of the Ativan use. The facility's own policy required assessment and documentation of symptoms and therapeutic goals prior to initiating psychotropic medications, but this was not followed. The lack of assessment, documentation, and monitoring led to the administration of a psychotropic medication without clear evidence of medical necessity, resulting in the resident being chemically restrained.