Failure to Use Non-Pharmacological Interventions and Obtain Informed Consent Before PRN Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs by not implementing or documenting required non-pharmacological interventions and not obtaining informed consent prior to administering certain medications. Facility policies on psychotropic medication use required that non-pharmacological interventions be attempted unless clinically contraindicated and that residents or their representatives be informed in advance of risks, benefits, and alternatives, with documentation of this informed consent. The facility’s pain management policy similarly required development, implementation, monitoring, and revision of interventions to manage pain, including a range of non-pharmacological measures. For one resident, the physician ordered Ativan 0.5 mg by mouth every six hours as needed for anxiety manifested by inability to relax, along with behavior monitoring that specified non-pharmacological interventions such as relaxation, adjusting room temperature/lighting, repositioning, toileting, music/television, and snacks, with outcomes to be documented every shift. The MAR for March showed Ativan was administered on multiple occasions, but the behavior monitoring documentation for the relevant dates and shifts listed the non-pharmacological interventions and outcomes as "NA," indicating they were not documented as attempted. The same resident had an order for Cymbalta 40 mg at bedtime for pain management, which was administered on two occasions in March. Review of the medical record showed no documented evidence that informed consent for Cymbalta was obtained prior to its administration, either via a written consent form or a narrative note. For another resident, the H&P documented that the resident had no capacity to make medical decisions. A physician’s order directed Tramadol 50 mg by mouth every six hours as needed for moderate pain. The orders did not include any directive for non-pharmacological interventions to be attempted prior to administering Tramadol. The MAR showed Tramadol was administered twice, and there was no documentation that non-pharmacological interventions were performed before giving the medication. During interviews, an RN confirmed that non-pharmacological interventions should be used for as-needed medications and acknowledged that there were no such interventions documented for this resident, and also verified the lack of behavior monitoring interventions for the first resident. The Administrator and DON were informed of and acknowledged these findings.
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