Failure to Attempt Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary psychotropic medications by not attempting non-pharmacological interventions prior to administering as-needed antianxiety medication. Facility policy required that person-centered, non-pharmacological approaches be used to minimize or discontinue psychotropic medication use unless contraindicated. However, for one resident with cognitive impairment, dementia, and a history of restlessness/agitation, there was no documented evidence that such interventions were attempted before administering Ativan (Lorazepam) on multiple occasions. Review of the resident’s clinical records and Medication Administration Record (MAR) showed that Ativan was given several times over a two-month period without documentation of prior non-pharmacological interventions. This was confirmed in an interview with the Director of Nursing, who acknowledged that these interventions should have been attempted before administering the medication. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.