Failure to Document Rationale for PRN Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to document the rationale for administering as needed (PRN) antipsychotic medications to a resident, as required by facility policy. The policy mandates that staff must assess and document the clinical rationale, including the resident's behaviors or symptoms that justify the use of PRN psychotropic medications, and record the effectiveness of the intervention. However, multiple reviews of the resident's Medication Administration Record (MAR) and progress notes revealed that staff consistently administered PRN antipsychotic and antianxiety medications without documenting the specific behaviors or evidence of anxiety that warranted their use. The resident involved had a complex psychiatric history, including diagnoses of schizophrenia, bipolar disorder, schizoaffective disorder, intermittent explosive disorder, and generalized anxiety disorder. The care plan and physician orders indicated the use of several scheduled and PRN psychotropic medications to manage behavioral symptoms such as aggression, agitation, and anxiety. Despite these directives, staff did not provide the required documentation in the progress notes to support the administration of PRN medications, even though the MAR indicated the medications were given and noted as effective. Interviews with staff, including an LPN, the DON, the Administrator, and the psychiatric provider, confirmed that documentation practices did not align with facility policy. Staff acknowledged that PRN medications were sometimes given based on the resident's request or non-verbal cues, but the necessary behavioral documentation was missing. The psychiatric provider also expected staff to document the resident's behaviors when PRN medications were administered to inform ongoing treatment decisions, but this was not consistently done.