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9/9/2015 Survey Tag 0576 Detail for:
Thursday, September 19, 2019 4:47 AM

Survey Date: 9/9/2015

Regulation Number:0576, level A scope/severity

Regulation Title: Medications - Admin of PRN Psychotropics

Regulation Description: 1.107 (5) (f) (i) Any drugs used to affect or modify behavior, including psychotropic drugs may not be administered by unlicensed persons as a "PRN" or "as needed" medication, except: (A) in those residential treatment facilities which are licensed to provide services for the mentally ill, or (B) where a resident understands the purpose of the medication, is capable of requesting the drug of his or her own volition and the facility has documentation from a licensed medical professional that the use of such drug in this manner is appropriate.

Surveyor Findings:

Based upon observation, record review and interviews, the facility failed to ensure that any drugs used to affect or modify behavior including psychotropic drugs were not administered by unlicensed persons as a "PRN" or "as needed" medication, to one sample resident (#5), who had an order for the administration of a PRN psychotropic medication. The findings:

Resident #5 was admitted to the facility on 8/3/15 with diagnoses including dementia.

A written physician's order, dated 8/4/15, directed the facility administer Buspar 10 mg one tablet every eight hours PRN. The instructions were transcribed accurately on the resident's August 2015 medication administration record (MAR). Non-licensed staff initials documented the medication was administered for "agitation" on the following dates: Two administrations on 8/6 and 8/9/15 and one administration on 8/5, 8/7, 8/8, 8/11, and 8/12/15.

A supply of the medication was found in the resident's medication area in the facility's medication cart.

According to Mosby's 2015 Nursing Drug Reference Manual, Buspar is classified as an anti-anxiety medication.

An unlicensed QMAP (qualified medication administration person) who was on duty during the onsite investigation and the health and wellness coordinator both stated that resident #5 was not capable of requesting the medication and understanding its purpose; and that the medication had been administered as a PRN by unlicensed, qualified administration staff.





Facility Plan of Correction:

P57 Medication- Administration of PRN Psychotropics
The management team will receive re-training on the Medication &Treatment- As needed PRN medications policy and Restraints policy on Nov 3, 2015 by the District Director Clinical Services (DDCS). The Health and Wellness Director to re-train the QMAPs at the next QMAP meeting on 11/9/2015 regarding the PRN medication policy and restraint policy. DDCS to complete random record review and MAR audit to monitor for compliance at routine site visits.


(1.How was the in-service with the management team documented?)

An in-service/training sign-in sheet will be provided to document that associates attended training, as well as a copy of the Medication and Treatment Administration Record policy, and the Medications and Treatments-PRN policy attached to the sign-in sheet.

(2.How often will the monitoring during site visits be occurring and how will that monitoring be documented?)

Community site visits will be conducted bi-annually by the DDCS or DDO, unless it is needed sooner. The visit will be documented on the site visit form and legal documentation in chart.

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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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