A 78 year old male resident with a diagnosis of dementia and high risk of falls was receiving Ativan and Risperdal, two psychotropic drugs often used to sedate residents and that increase fall risks. On 9/18/12, the resident was given extra doses of Ativan to further chemically restrain him. That night, the resident fell and broke his arm. The resident’s one-to-one caregiver assigned in part to prevent falls, was not around. The facility was cited for failing to ensure the resident was free from excessive, inappropriate, and ineffective medication and for failing to provide the needed one-to-one supervision.
The facility was assessed a $10,000 fine, in part because Ativan is supposed to be avoided for elderly patients. Ativan is inappropriate for treating insomnia, agitation, or delirium and it increases risk factors and symptoms often associated with dementia: impaired cognition and risk of falls and fractures. While the citation did not explore possible chemical restraint or non-pharmacologic options in addressing resident behavior, it did take issue with the common reasons nursing homes use Ativan on their residents.
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Violation of the Month Archive