Failure to Ensure Timely Re-evaluation and Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from potential chemical restraints related to the use of psychotropic medications. Clinical record review showed that a resident with Alzheimer's disease, dementia, and anxiety was cognitively impaired and had been administered an anti-anxiety medication. A physician ordered Ativan to be given every five hours as needed for agitated behaviors, but the order did not specify a stop date. The Medication Administration Record indicated that the medication was administered on five separate occasions. There was no documented evidence that the physician re-evaluated the continued use of the as-needed anti-anxiety medication beyond 14 days, and staff confirmed that no stop date had been added to the order.