Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Use
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication, specifically Ativan, beyond the 14-day limit for a resident diagnosed with dementia, anxiety, and gastroesophageal reflux disease. The clinical record for this resident showed an initial order for PRN Ativan for 14 days, followed by a renewed order for another 14 days without documentation of a clinical rationale for the continued use. This action was not in accordance with the facility's policy, which requires a documented clinical rationale and evaluation by the provider for continued PRN psychotropic medication use beyond 14 days. Additionally, the resident's medication administration record indicated that PRN Ativan was administered on multiple occasions, but there was no evidence in the clinical record that non-pharmacological interventions were attempted prior to each administration, as required by facility policy. The Director of Nursing confirmed the absence of both a clinical rationale for the continued PRN order and documentation of non-pharmacological interventions prior to medication administration.