Failure to Document Non-Pharmacological Interventions and Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medication for a resident diagnosed with dementia and anxiety. The resident was prescribed lorazepam to be administered as needed for agitation. On two occasions, lorazepam was given to the resident, but there was no documented evidence that non-pharmacological interventions were attempted prior to administering the medication. Additionally, there was no documentation in the electronic medication administration record (EMAR) indicating that side effects of lorazepam were monitored after administration. Furthermore, the facility did not document episodes of adequate behavior monitoring related to the use of lorazepam for this resident. During an interview, the DON confirmed that nursing staff did not document attempts at non-pharmacological interventions, nor did they monitor or document side effects or adequate behavior following administration of the psychotropic medication. The facility's own policy required non-drug interventions and documentation of both behavioral manifestations and side effects, but these steps were not followed in this case.