F0605

D

Failure to Attempt and Document Non-Pharmacologic Interventions Before PRN and Scheduled Lorazepam Use

Rensselaer, Indiana Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that non-pharmacological interventions were attempted and documented prior to administering PRN lorazepam for anxiety and agitation, and before converting it to a scheduled medication, for a resident with Alzheimer’s disease. The resident had multiple PRN lorazepam orders beginning in early December, with doses administered on numerous dates in December and January for behaviors such as yelling, agitation, and inappropriate comments. Nursing progress notes occasionally described behaviors like yelling in the dining room or at other residents, but consistently lacked documentation that any non-pharmacological interventions were attempted before giving the medication, despite a behavioral health policy stating that pharmacologic interventions should only be used when non-pharmacologic measures are ineffective or clinically indicated.

On several dates when lorazepam was administered, there was no documentation at all on the MAR, behavior sheets, or progress notes describing what behaviors the resident was exhibiting at the time of administration. Even when behaviors were described, such as yelling at staff and residents or becoming aggressive after medication, there was still no indication that staff tried interventions like redirection, removal from the situation, or environmental modification before administering the PRN medication. The resident’s care plan, initiated in early January, identified physical aggressiveness, poor impulse control, and a history of physical altercations with other residents, and included interventions such as assessing and anticipating needs, using physical and verbal cues to alleviate anxiety, and documenting behaviors and attempted interventions. However, the documentation reviewed did not show that these care-planned interventions were implemented prior to medication use.

Later, staff reported to a psychiatric NP that the resident’s behaviors had increased after the PRN lorazepam order expired, and that the resident had been receiving lorazepam routinely in the morning and evening prior to meals. Based on this report and discussion with the DON and Social Service Director, the NP ordered lorazepam 0.5 mg twice daily on a routine basis for generalized anxiety disorder. There was no documentation in the progress notes or MAR of behaviors between the end of the last PRN order and the start of the scheduled lorazepam, aside from behavior monitoring entries on a few dates in early February that showed both effective and ineffective non-pharmacological interventions. During interview, the DON acknowledged that there had been no interventions documented prior to lorazepam administration before early February, and the Administrator could not provide a facility policy specific to PRN medication administration, only the behavioral health policy requiring non-pharmacologic measures first.