Failure to Document Rationale and Non-Pharmacological Interventions for PRN Antianxiety Medication
Penalty
Summary
The facility failed to document specific behaviors, signs, and symptoms of anxiety that justified the administration of a PRN antianxiety medication for one resident. The resident, who was cognitively intact and had a diagnosis of anxiety, had an active physician order for PRN Xanax. On one occasion, the medication was administered with the reason documented as 'generalized, not feeling well,' but there was no documentation of the specific anxiety-related behaviors or symptoms that prompted the use of the medication. Additionally, the electronic medical record did not contain evidence that non-pharmacological interventions were attempted prior to administering the PRN medication, as required by facility policy. The Director of Nursing confirmed the absence of documentation regarding both the specific need for the medication and the use of non-pharmacological interventions. The facility's policy mandates that such interventions and their effects be documented as part of the care planning process.