Failure to Document PRN Psychotropic Duration and Non-Pharmacological Interventions
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medication use. Specifically, for a resident with schizophrenia, the physician's order for prn (as needed) lorazepam did not include documentation of the intended duration of use, as required by facility policy. The nurse practitioner continued the prn lorazepam order without specifying the duration, and there was no documentation from the physician or nurse practitioner regarding how long the prn medication should be used. Additionally, the clinical record and medication administration records showed that lorazepam was administered on several occasions without evidence that non-pharmacological interventions were attempted prior to giving the medication. Staff interviews confirmed that non-pharmacological interventions should be individualized and attempted before administering prn lorazepam, and that such attempts should be documented in the progress notes. However, no such documentation was found for the dates when lorazepam was given.