Failure to Document Indications for Psychoactive Medication Administration
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of behaviors and clinical indications prior to administering psychoactive medications for a resident with diagnoses including anxiety disorder, encephalopathy, and chronic pain. Clinical record review showed that the resident received multiple doses of PRN Lorazepam without documented evidence of anxiety-related behaviors or symptoms to justify its use. On several occasions, the Medication Administration Record (MAR) indicated that Lorazepam was administered even when the resident was not exhibiting anxiety, and the Documentation Survey Report confirmed no anxiety behaviors were present on those dates. The resident also reported not requesting Lorazepam and stated that staff administered it in addition to pain medication to help with sleep, rather than for anxiety. Further review revealed that Lorazepam was frequently given in combination with a prescribed opioid pain medication, Hydrocodone/Acetaminophen, without proper documentation of clinical need for the psychoactive medication. The facility was unable to provide supporting documentation for the administration of Lorazepam, and the Director of Nursing confirmed that monitoring of behaviors and clinical indications was not consistently documented. This lack of documentation and monitoring led to the administration of psychoactive medication without appropriate indication, as required by regulation.