Failure to Attempt Alternatives Before Administering Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident was free from chemical restraint by not documenting or attempting alternative interventions prior to administering Xanax (Alprazolam), a psychotropic medication. The resident in question was admitted with a diagnosis that included anxiety and was assessed as cognitively intact, scoring 14 out of 15 on the Brief Interview for Mental Status (BIMS). The physician's order allowed for Xanax to be given as needed for anxiety via PEG-tube for 14 days, and the medication administration record showed that the resident received Xanax on multiple occasions. During interviews, administrative and clinical staff confirmed that there was no evidence of attempts at alternative interventions before administering the medication. This lack of documented or attempted non-pharmacological interventions prior to the use of a controlled drug constituted a failure to prevent the unnecessary use of psychotropic medications and the use of a chemical restraint.