Lack of Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s psychotropic medication regimen was free from unnecessary medication use and that non-pharmacological interventions were implemented as required by facility policy. The facility’s policy on psychotropic medications, dated February 12, 2026, stated that residents using psychotropic drugs should also receive non-pharmacological interventions to facilitate reduction or discontinuation of these drugs. Resident 42’s quarterly MDS assessment dated March 12, 2026, documented that the resident was cognitively intact, required staff assistance for daily care needs, and had diagnoses including dementia and depression. Physician orders for Resident 42 between early January and mid-March 2026 directed administration of 0.50 mg Lorazepam every eight hours as needed for anxiety/agitation for 14-day periods. The MARs for January, February, and March 2026 showed multiple administrations of 0.50 mg Lorazepam on specific dates and times across those months. However, there was no documented evidence that non-pharmacological interventions were attempted prior to administering Lorazepam on any of those occasions. In an interview on March 25, 2026, the Nursing Home Administrator confirmed that there was no documentation of non-pharmacological interventions before the PRN Lorazepam doses and acknowledged that such documentation should have been present.
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