Failure to Attempt Non-Pharmacological Interventions Before Administering Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically Ativan, for two residents who were cognitively impaired and dependent on staff for care. Both residents had physician orders requiring that non-pharmacological interventions be attempted and documented prior to administering anti-anxiety medication. However, review of the Medication Administration Records (MAR) for both residents over several months showed multiple instances where Ativan was administered without any documented evidence that non-pharmacological interventions were attempted beforehand. Clinical records and staff interviews confirmed that, despite facility policy and physician orders, staff did not attempt or document non-pharmacological interventions prior to administering Ativan to these residents. This was further corroborated by the Nursing Home Administrator, who acknowledged that such interventions were not attempted before medication administration on the identified dates and times.