§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic
Based on a comprehensive assessment of a resident, the facility must ensure that---
§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;
§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;
§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and
§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.
§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
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Observations:
Based on review of facility procedure, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents did not receive antianxiety medications unless necessary and that behavior interventions were attempted before use for two of five residents reviewed (Residents #109 and #127).
Findings include:
Review of the facility's "Behavioral Symptom Evaluation and Documentation Process" of 2017 revealed that when a patient demonstrates a new onset behavior, staff are to document the observed behavior. Additionally, the interdisciplinary team is to develop, modify, and initiate a care plan with individualized nonpharmacological interventions.
Review of Resident #109's physician's orders revealed an order for Ativan Solution 0.5 milligrams sublingually (under the tongue) every four hours as needed for anxiety related to anxiety disorder.
Review of Resident #109's October Medication Administration Record (MAR) revealed that Ativan was administered on October 6, 11, and 24, 2019. Review of Resident #109's November MAR revealed that Ativan was administered on November 1, 4, 13, 20, and 23.
Further review of the clinical record revealed that no behaviors were documented prior to the administration of Ativan on October 11, 24, 2019, and November 1, 4, 13, and 23, 2019. Additionally, there was no documented evidence that behavior interventions were attempted before the administration of Ativan on October 6, 2019, and November 20, 2019.
Review of Resident #127's physician's orders revealed an order for Ativan Solution 0.25 milliliters every two hours as needed for anxiety.
Review of Resident #127's November MAR revealed that Ativan was administered on November 22, 23, 26, 28, and 29, 2019. Review of Resident #127's December MAR revealed that Ativan was administered on December 1 and 2, 2019.
Further review of the clinical record revealed that no behaviors were documented prior to the administration of the Ativan.
Interview with the Director of Nursing on December 5, 2019, at 11:05 a.m. confirmed that behaviors and/or behavior interventions were not documented prior to the administration of Ativan.
42 CFR 483.45 (c)(3) Unnecessary Medications
Previously cited 11/8/18
28 Pa. Code: 201.18(b)(1) Management
Previously cited 10/30/19, 8/16/19, 11/8/18
28 Pa. Code: 211.5(f) Clinical records
Previously cited 10/30/19, 11/8/18
28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 11/8/18
| | Plan of Correction - To be completed: 01/14/2020
The facility failed to ensure that residents did not receive antianxiety medications unless necessary and that behavior interventions were attempted before use for two of five residents reviewed #109 and #127
Non-pharmacological interventions have been added to both Resident's #109 and #127 Antianxiety medication orders. CRNP will complete a medication review for antianxiety medications for both residents.
Current residents and new admissions prn psychotropic medications will be reviewed for appropriate care and services using the Psychotropic Medication QAPI Tool
Licensed Nurses will be educated to Focus on F Tag F758 Free from Unnec Psychotropic Meds/Prn Use
Utilizing the Psychotropic Medication QAPI Tool Random Audits of resident on prn psychotropics will be completed by DON/designee weekly x4
Trends to be submitted to QAA for review and recommendations as indicated
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