Failure to Limit PRN Psychotropic Medication Orders and Prevent Chemical Restraints
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that a resident was free from chemical restraints. A resident with cognitive impairment, Type II Diabetes, CHF, anxiety disorder, and chronic pain syndrome, who required substantial to maximal assistance with ADLs and hygiene, was prescribed Lorazepam 0.5 mg to be given every 12 hours as needed for anxiety, restlessness, or agitation for a 30-day period. The order was placed without documented rationale for exceeding the 14-day limit for PRN psychotropic medications, as required by facility policy. The medication was administered three times during this period, and the Unit Manager confirmed that the order was extended to 30 days without the necessary documentation or rationale in the medical record.