Failure to Ensure Medical Necessity and Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were only administered when medically necessary for two of three residents reviewed. For one resident with vascular dementia and psychotic disturbance, Lorazepam was prescribed and administered on multiple occasions for anxiety/agitation associated with shower days. However, a review of the medical record revealed that this resident did not have a documented diagnosis of anxiety, despite the medication being ordered for that purpose. The Director of Nursing (DON) confirmed that staff are expected to ensure an appropriate diagnosis is present prior to starting any medication, and acknowledged the absence of an anxiety diagnosis for this resident. For another resident with unspecified dementia and insomnia, Lorazepam was ordered to be given every four hours as needed (PRN) for restlessness, anxiety, or insomnia, with no specified end date. The medical record did not contain a rationale from the provider explaining why the PRN order was to continue for longer than 14 days, as required. The DON confirmed that the order was indefinite and that the necessary provider rationale for extended PRN use was missing from the record.