Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of PRN Ativan without appropriate justification or documentation. The resident had a physician's order for Ativan 0.5mg every 12 hours as needed, but the order lacked a specified time limit. Although the pharmacy recommended discontinuing the PRN Ativan or reordering it with a specific duration, the physician did not update the order until several weeks later. During this period, the medication was administered for reasons not consistent with treating a medical symptom, such as the resident attempting to get up unassisted, which does not meet the regulatory requirements for psychotropic medication use. Additionally, the documentation for 29 doses of PRN Ativan administered over several weeks failed to include specific behaviors or non-pharmacologic interventions attempted prior to medication administration. The only behavior documented was 'increased agitation,' as stated in the physician's order, without further detail or evidence of alternative interventions. This lack of detailed documentation and failure to use the least restrictive alternatives contributed to the deficiency identified during the survey.