Failure to Document Nonpharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to provide and document appropriate nonpharmacological interventions prior to administering as-needed (PRN) psychotropic medications for three of five residents reviewed for unnecessary medication use. For one resident with diagnoses including anxiety, depression, psychotic disorder, schizophrenia, and PTSD, the medical record showed frequent administration of PRN diazepam over several months. However, there was no documentation of nonpharmacological interventions attempted before medication administration, despite explicit instructions from the consulting pharmacist and physician orders requiring such documentation. Another resident with diagnoses of bipolar disorder with psychotic features, anxiety disorder, and schizoaffective disorder was administered PRN hydroxyzine multiple times. The medication administration records indicated the medication was effective but lacked any documentation of nonpharmacological interventions prior to administration. The resident's care plan listed several nonpharmacological strategies, but progress notes and the electronic medical record did not reflect that these were attempted before giving the medication. Interviews with nursing staff and the assistant director of nursing confirmed the expectation that nonpharmacological interventions should be offered and documented prior to PRN psychotropic medication administration. Review of facility policy also indicated that nurses are required to attempt an intervention before administering PRN psychotropic medication. Despite these requirements, documentation in the medical records did not show that nonpharmacological interventions were attempted or recorded prior to medication administration for the residents reviewed.