The psychiatric nurse practitioner who prescribed Hydroxyzine for Resident #3 at Towson Rehabilitation and Healthcare Center told federal inspectors in October that he "intended for it to be given PRN" — medical shorthand for "as needed." Instead, nurses administered the 10-milligram doses every morning at 9 a.m. and evening at 5 p.m.
"I recommended the 10 mg. of Hydroxyzine as a PRN," the practitioner said when inspectors informed him of the scheduling error.
The resident had been admitted in September with metabolic encephalopathy, dementia with behavioral disturbances, anxiety disorder, depression, and altered mental status. By early October, staff documented increasing problems.
A change-in-condition note from October 2 described "increased anxiety and restlessness" with "frequent redirection due to impulsive behaviors, including repeated attempts to ambulate without assistance." The resident was evaluated by psychiatry, which ordered Buspar 5 milligrams twice daily for anxiety management after getting family authorization.
Within a week, the situation escalated. A psychiatry note from October 9 documented "ongoing yelling and agitation" with staff reporting "moderate aggression and anxiety." The psychiatrist observed the resident as "restless, verbally aggressive, and irritable" with an "intense" affect showing "ongoing agitation and behavioral dysregulation."
The psychiatrist increased the Buspar to 7.5 milligrams twice daily and added Hydroxyzine 10 milligrams "as needed x 14 days for escalating anxiety and agitation." Hydroxyzine is an antihistamine prescribed for short-term anxiety relief.
But when nursing staff transcribed the order, they scheduled it as a regular twice-daily medication rather than as needed. The medication administration record showed Hydroxyzine started October 11 and given at 9 a.m. and 5 p.m. daily.
The transcription error meant the resident received the drug regardless of symptoms. Federal regulations require nursing homes to ensure residents' drug regimens are free from unnecessary medications — a standard designed to prevent overmedication, particularly of vulnerable populations like dementia patients.
Staff were supposed to monitor the resident's behavior each shift to determine when the anxiety medication was warranted. Inspection records showed behavior monitoring was occurring, but nurses "were only putting check marks in the box and not describing the behaviors that the resident was displaying."
The Director of Nursing confirmed to inspectors that "it was a transcription error, that the Hydroxyzine should have been PRN and not twice per day." She also acknowledged that staff weren't documenting specific behaviors, only noting "that behaviors were sometimes occurring."
The documentation failure compounded the medication error. Without detailed behavior records, staff couldn't determine whether the resident actually needed the anxiety medication at scheduled times, or if the symptoms that originally prompted the prescription were improving or worsening.
Hydroxyzine carries particular risks for elderly patients. As an antihistamine with sedating properties, it can cause confusion, falls, and other complications in seniors, especially those with dementia. The Beers Criteria, widely used guidelines for prescribing to older adults, recommend avoiding antihistamines like Hydroxyzine in patients over 65 due to these risks.
The psychiatric nurse practitioner's intention to limit the medication to "as needed" use reflected appropriate caution for this vulnerable population. PRN scheduling allows staff to assess whether a resident's anxiety or agitation actually requires medication intervention, or whether non-drug approaches might be effective.
Instead, the resident received Hydroxyzine twice daily for at least two weeks, potentially experiencing unnecessary sedation and other side effects. The lack of detailed behavior documentation meant staff had no way to evaluate whether the medication was helping or harming the resident's condition.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" but noted it affected the facility's compliance with unnecessary drug regulations. The finding emerged during a complaint survey, suggesting someone had raised concerns about medication practices at the facility.
The case illustrates how seemingly minor administrative errors can compromise patient safety in nursing homes. A transcription mistake combined with inadequate documentation created a situation where a dementia patient received potentially inappropriate medication for weeks without proper monitoring.
The resident's family had authorized the original Buspar prescription after being notified of their loved one's increased anxiety and behavioral issues. They were not mentioned in connection with the Hydroxyzine scheduling error, leaving unclear whether they were aware their family member was receiving additional psychiatric medication on a routine rather than as-needed basis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Towson Rehabilitation and Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
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