Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to facility policy, as needed (PRN) psychotropic medications should only be administered when necessary to treat a specific, documented condition, and any PRN order for such medications extending beyond 14 days requires a documented rationale from the practitioner, including the duration of the order. For a resident with cognitive impairment and a diagnosis of dementia, there was an active PRN order for hydroxyzine to be given every four hours as needed for anxiety. The medication was administered on several occasions over a period exceeding 14 days, but there was no evidence in the clinical record that a practitioner documented a rationale for extending the PRN order or specified the duration of its use. Additionally, the facility did not document that non-pharmacological interventions were attempted prior to administering hydroxyzine on multiple occasions, as required by policy. Interviews with the Director of Nursing confirmed the absence of documentation for both the rationale for extending the PRN order and the use of non-pharmacological interventions before administering the medication. These findings indicate non-compliance with facility policy and regulatory requirements regarding the use of psychotropic medications.