Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that symptoms of potential psychiatric distress were consistently recorded and that non-pharmacological interventions were attempted and documented prior to the administration of as-needed (PRN) psychotropic medications for a resident. The resident in question had both long-term and short-term memory impairment, experienced hallucinations, and exhibited behaviors such as yelling, cursing, accusations, and physical aggression. The care plan for this resident included multiple non-pharmacological interventions, such as redirection and providing a calm environment, and directed staff to monitor and record occurrences of target behaviors and interventions. Despite these directives, documentation revealed multiple instances where PRN psychotropic medications, including haloperidol and lorazepam, were administered without clear evidence that non-pharmacological interventions were attempted first. For example, on one occasion, haloperidol was given for agitation and yelling, but the record did not indicate what, if any, non-pharmacological measures were tried beforehand. On another occasion, lorazepam and Dilaudid were administered at nearly the same time, but the documentation lacked details on the symptoms presented, the rationale for giving both medications, and any non-pharmacological interventions attempted prior to medication administration. Interviews with staff confirmed that non-pharmacological interventions should be attempted and documented before administering PRN psychotropic medications, and that symptoms and interventions should be clearly recorded. The assistant director of nursing acknowledged the lack of consistent documentation regarding symptoms and non-pharmacological interventions in the resident's medical record, confirming that this was an area needing improvement.