Failure to Document Non-Pharmacological Interventions Before PRN Anti-Anxiety Medication
Penalty
Summary
Facility staff failed to document non-pharmacological interventions attempted prior to administering anti-anxiety (AA) medication to a resident diagnosed with anxiety disorder. The resident was admitted with a diagnosis of anxiety disorder and was prescribed clonazepam 0.5 mg every 8 hours as needed. Over the course of two months, the medication was administered multiple times, but the clinical record and Medication Administration Record (MAR) lacked documentation of non-pharmacological interventions attempted before each administration. The resident's care plan did not include information about the use of AA medication or the non-pharmacological interventions used or attempted prior to administration. Interviews with staff revealed that, until recently, there was no process in place for documenting non-pharmacological interventions prior to PRN AA medication administration. The electronic MAR system had only recently been updated to prompt staff to document such interventions, but prior to this update, no documentation was required or completed. Additionally, the Director of Nursing confirmed that the facility did not have a policy regarding psychotropic medication use and non-pharmacological interventions.