Failure to Document NPIs and Indications Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use, specifically regarding the administration of Ativan (Lorazepam) on an as-needed basis. Record review showed that the medication was administered 16 times in one month, but there was no documentation that non-pharmacological interventions (NPIs) were attempted or provided prior to giving the medication. Additionally, there was a lack of documentation indicating that the resident exhibited behaviors that would justify the use of the psychotropic medication on several occasions. Interviews with the Nurse Manager revealed that nursing staff are expected to document both the behaviors leading to the administration of psychotropic medications and the NPIs attempted beforehand. Multiple avenues for such documentation were available, including the eMAR, medication orders, progress notes, and behavior monitoring tasks. Despite these expectations and available methods, the required documentation was not present in the resident's medical record for the identified dates.