Unnecessary Drug Administration and Inadequate Behavior Monitoring
Penalty
Summary
A deficiency was identified when a resident with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, anxiety disorder, depression, and altered mental status was administered Hydroxyzine 10 mg twice daily on a routine basis, despite the medication being ordered as PRN (as needed) for escalating anxiety and agitation. The medication was started following a psychiatric evaluation for increased anxiety, restlessness, and impulsive behaviors. However, the medication administration record showed that Hydroxyzine was given at scheduled times rather than in response to specific symptoms, due to a transcription error. Additionally, behavior monitoring documentation was incomplete, as nursing staff only marked checkboxes without providing descriptions of the resident's behaviors. This lack of detailed documentation failed to demonstrate the necessity for the PRN medication and did not provide adequate information about the resident's behavioral symptoms. Both the psych nurse practitioner and the DON confirmed the medication was intended to be PRN and acknowledged the documentation and transcription errors.