§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§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.
§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
§483.45(e) Psychotropic Drugs. 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 upon clinical record review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were completed prior to the administration of as needed anti-anxiety medication for one of five residents reviewed (Resident 51).
Findings include:
Review of Resident 51's physician's orders revealed an order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) to be administered every four hours as needed for anxiety/restlessness.
Review of Resident 51's January Medication Administration Record (MAR) revealed Resident 51 received Ativan 0.5 mg on January 1, January 2, January 3, January 5, January 6, January 8, January 9, January 10, January 11, January 21, January 22, January 26 and January 27, 2026.
Review of Resident 51's clinical record failed to reveal evidence that non-pharmacological interventions were attempted prior to the administration of as needed Ativan on the above-mentioned dates.
Interview with the Nursing Home Administrator and Director of Nursing on January 30, 2026, at 10:50 a.m. confirmed that no non-pharmacological interventions were attempted prior to the administration of the as needed Ativan.
28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services
| | Plan of Correction - To be completed: 03/16/2026
1.Nonpharmacological interventions have been incorporated into Resident #51's plan of care. Psychotropic orders in PCC have been modified to require nonpharmacological interventions.
2.Nonpharmacological interventions have been incorporated into care plans. Orders in PCC for psychotropic medications have been modified to require nonpharmacological interventions prior to medication administration.
3.Modifications have been made to PCC such that the psychotropic medications are not able to be administered without first documenting that nonpharmacological interventions have been attempted. Licensed Staff will be provided education regarding requirement that nonpharmacological approaches be attempted and documented prior to administration of the medication.
4.Audits will be conducted three times weekly times four weeks to ensure accurate order entries. Results will be presented at QAPI for review and recommendations.
5. March 16th, 2026
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