F0605

D

Failure to Manage and Document PRN Psychotropic (Ativan) Use and Respond to Family Concerns

Grayville, Illinois Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to appropriately manage and document the use of the psychotropic medication Ativan for one resident with dementia, anxiety, depression, and Alzheimer’s disease. The resident’s diagnoses included unspecified dementia with agitation, generalized anxiety disorder, Alzheimer’s disease, and depression. The resident’s care plan identified multiple behavior-related focus areas, including anxiousness, restlessness, destructiveness, potential physical aggression, delusional thinking, hallucinations, delirium, and acute confusion, with interventions that included administering psychotropic medications as ordered and monitoring for effects and effectiveness every shift. The Minimum Data Set documented that the resident was not cognitively intact, had frequent depressive symptoms, and exhibited behaviors such as hitting, scratching self, pacing, rummaging, public sexual acts, and public disrobing, and that the resident was on high-risk drug classes including an antipsychotic and an antidepressant.

The facility’s records showed multiple Ativan orders with inconsistent and clinically questionable indications and inadequate documentation. An initial PRN Ativan order for 0.5 mg every 12 hours was entered with an indication of nausea related to depression, followed by a second PRN order for the same dose every 12 hours for comfort related to Alzheimer’s disease, and later a routine order every 12 hours for anxiety, aggression, and agitation related to generalized anxiety disorder. The nurse practitioner later stated that the first indication (nausea related to depression) was something she had only seen in hospice and not related to depression, and that neither the first nor second indication (comfort related to Alzheimer’s) was appropriate. The February MAR showed that the resident received PRN Ativan multiple times under these orders, but progress notes documented the symptoms or reasons for administration on only 1 of 7 PRN doses under the first order and 1 of 4 PRN doses under the second order. Nursing staff, including the DON and an LPN, stated they did not believe it was necessary to write a progress note each time a PRN medication was administered and believed the diagnosis on the MAR was sufficient, and one LPN could not recall the resident’s symptoms at the time she administered Ativan.

The facility also failed to respond appropriately to a pharmacy review and to family concerns regarding Ativan use. A pharmacist’s medication review form for the PRN Ativan order requested that the prescriber choose among options to discontinue, add a stop date per CMS 14-day PRN psychotropic guidelines, or extend the order with a specified duration, indication, and rationale. None of these options were selected, and the prescriber response section was left blank, with no indication that the prescriber acknowledged or signed the review. The administrator acknowledged that PRN psychotropic medications should be reviewed within 14 days and either reordered or discontinued and was unsure why this review was missed. The resident’s power of attorney and another family member reported that Ativan had previously caused an idiosyncratic, opposite reaction at home, that they had stopped it before admission, and that they requested on multiple occasions that Ativan not be administered. They stated they were not informed when Ativan was discontinued and then reordered, and one family member denied giving verbal consent for Ativan use. Nursing staff, including an RN and an LPN, reported that each time the resident received Ativan he became more aggressive, violent, and agitated, and one RN stated she had voiced concerns to the DON. Despite these reports and the family’s requests, Ativan was reordered and administered multiple times, with inadequate documentation of indications and without clear evidence of prescriber review or acknowledgment of the pharmacist’s recommendations.