Failure to Limit and Document Use of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications and that non-pharmacological interventions were attempted prior to administering as-needed (PRN) psychotropic medications. Facility policy required minimizing the use of psychotropic medications, avoiding unnecessary drug use, and promoting non-pharmacological interventions. However, for four residents reviewed, there was no documented evidence that these requirements were met. For multiple residents with cognitive impairment and diagnoses such as dementia, depression, and anxiety, physician orders prescribed PRN Ativan for agitation or anxiety. In several cases, the medication was administered beyond the 14-day limit without documented physician rationale for continuation, as required. Additionally, review of Medication Administration Records and clinical documentation revealed that staff did not document attempts at non-pharmacological interventions prior to administering PRN Ativan, despite care plans and psychiatric consults specifying this requirement. Interviews with the Director of Nursing confirmed the lack of documentation for both the required physician rationale for extended PRN psychotropic use and the use of non-pharmacological interventions prior to medication administration. These findings were observed for four residents over multiple months, indicating a pattern of non-compliance with facility policy and regulatory requirements regarding psychotropic medication management.