How can we turn care plans from an exercise in paper compliance that few staff understand, let alone review or utilize, to a workable document that helps us manage resident needs? When thinking about how to create an effective care plan for an “as needed” (PRN) psychotropic medication, and to reduce the risk of use of unnecessary medication and/or chemical restraint, we need to understand the regulations surrounding this situation.
A review of the requirements in F656 Comprehensive Care Pans Develop and Implement a Comprehensive Care Plan, along with the General Critical Element Pathway [(CEP) CMS-20072], guides us to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs and includes the resident’s goals, desired outcomes, and preferences. In F605 Right to Be Free from Chemical Restraints we find that CMS (Centers for Medicare and Medicaid Services) addresses psychotropic medications that have the potential to create symptoms consistent with sedation; when these medications are used for discipline or staff convenience and not required to treat the resident’s medical symptoms, these medications would be considered a chemical restraint. CMS also recognizes that even if the intent was not to sedate or subdue the resident, an unnecessary medication administration may also have the effect of chemical restraint. Additionally, guidance in F757 Unnecessary Drugs and Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review [(CEP) CMS-200082] provides useful insights on the care CMS anticipates we are providing for residents who are at risk for chemical restraint.
Prescribing PsyChotropic Medication
There are legitimate circumstances when a PRN psychotropic medication is prescribed to treat a diagnosed specific condition. Examples of situations appropriate for an order for PRN psychotropic medication could include while the dose is adjusted, to address acute or intermittent symptoms, or in an emergency. CMS has set a 14-day time limit for PRN psychotropic medication orders, and the State Operations Manual (SOM) describes specific instructions for extending that 14-day restriction.
- For psychotropic medications that are not antipsychotic, the order may be extended beyond 14 days. The attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record along with a specific duration. For example, extending a PRN order for a benzodiazepine for seizure management may be appropriate with supporting provider rationale and duration documented.
- When a provider orders a PRN antipsychotic medication and believes it is appropriate to renew the order for the PRN antipsychotic after the 14-day time limit, the attending physician or prescribing practitioner must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. In this case, the attending physician or prescribing practitioner must directly examine the resident and assess the resident’s current condition and progress to determine if there is still a need for the PRN antipsychotic medication order. CMS also notes that facility staff reporting of the resident’s condition to the attending physician or prescribing practitioner does not actually constitute an evaluation.
Care Plans for Psychotropic Medication
Creating a care plan to manage a newly ordered PRN psychotropic medication is optimally done at the outset of the order. When a care plan is created in conjunction with the order, we can reduce the risk for inappropriate use and adverse outcomes of PRN psychotropic medication, including chemical restraint. Many electronic health records allow specific care plan approaches to be pushed to the MAR/TAR as nursing orders for staff review and completion. Prompts from the care plan to the MAR/TAR can support the care plan goal for the use of the PRN psychotropic medication (example – resident’s distress related to hallucinations/delusions will not result in injury to resident or others during the next 14 days).
Components of a care plan for a PRN psychotropic medication with prompts pushed to nursing documentation could include:
- Prompts for verification that the resident or responsible party has been informed of the benefits, risks, and alternatives to use of psychotropic medication, including black box warnings, prior to implementation of the order, with documentation in the record
- Prompts for documentation of specific symptoms or behaviors the medication is indicated for (example – PRN antipsychotic to manage hallucinations and/or delusions that are distressing to the resident or places the resident or others at risk for injury)
- Prompts for documentation of specific non-pharmacological approaches that were attempted for specific behaviors (examples – environmental change, reality orientation or validation, distraction, activities, etc. to relieve the symptoms of distress)
- Prompts for documentation of the results of the PRN psychotropic medication use (examples – resolution of hallucinations/delusions, decrease in distress symptoms, etc.)
- Prompts for monitoring/documentation of specific side effects (examples – sedation, loss of appetite, decline in ADL, incontinence, etc.)
- Prompts for weekly interdisciplinary team (IDT) review of behaviors and PRN psychotropic medication use, including the supporting documentation
- Prompts for provider review/reassessment of symptoms and need to continue specific PRN psychotropic medication at the end of the 14-day period as required by CMS
Finally, when the PRN psychotropic medication is discontinued the care plan that addresses the use of the PRN psychotropic medication can be discontinued/resolved. This process could also be adapted to initiation of scheduled psychotropic medication use, increase of dose of psychotropic medication, as well as gradual dose reductions.
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