Failure to Monitor PRN Anti-Anxiety Medication Use
Penalty
Summary
Facility staff failed to ensure a resident’s drug regimen was free from unnecessary medications when they did not implement behavioral monitoring for an as-needed anti-anxiety medication. The facility’s undated “Unnecessary Drugs” policy stated that medications would be monitored to ensure effectiveness. The resident was admitted with diagnoses of borderline personality disorder and anxiety and was her own responsible party. The resident’s anxiety care plan, dated 11/23/25, directed staff to monitor and track the resident’s behaviors. A physician’s order dated 11/22/25 prescribed hydroxyzine 50 mg every six hours as needed for anxiety, targeting symptoms of worry that needs were not being met due to anxiety. During an interview and concurrent record review on 2/26/26, the DON confirmed that from admission through 2/26/26 there was no behavioral monitoring in place to track signs or symptoms of anxiety, and stated that the purpose of such monitoring is to count the number of episodes and monitor the effectiveness of the medication. This lack of behavioral monitoring for the resident receiving PRN hydroxyzine for anxiety resulted in the facility not ensuring the resident’s medication regimen was monitored for effectiveness as required by facility policy and the resident’s care plan, and had the potential for the resident to not maintain their highest practicable mental, physical, and psychosocial well-being.
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