Failure to Limit PRN Antipsychotic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for antipsychotic medications were limited to 14 days, as required by their policy and regulations. Specifically, Resident 4 had a PRN order for Seroquel, an antipsychotic medication, which was prescribed without a stop date, starting on December 31, 2024. This order was not renewed or evaluated for appropriateness within the 14-day period, as mandated by the facility's policy. The Director of Nursing acknowledged the oversight during an interview, confirming that the facility should comply with the regulation requiring a 14-day stop date for PRN antipsychotic medications. Resident 4's clinical record indicated diagnoses of dementia, major depressive disorder, and anxiety disorder, which are conditions that may require careful management of medications. Despite an assessment by a practitioner on January 13, 2025, which included a plan to continue medications as recommended by psychiatric services, the PRN order for Seroquel was not updated or reviewed within the required timeframe. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its own policy and regulatory requirements.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0758- Free from Unnecessary Psychotropic meds/PRN use 1. Resident #4 PRN order for antipsychotic medication was reviewed with physician and discontinued on 1/23/25. 2. All PRN psychotropic orders were reviewed to ensure the order had an appropriate stop date per regulatory compliance. No other discrepancies found. 3. Policies for Psychotropic and Anti-psychotic Medications reviewed and any necessary revisions made by DON. Re-education to all Licensed Nurses on Psychotropic Medication use including every PRN order having a 14 day stop date will be provided via Relias to be completed by 2/21/2025. 4. QA Coordinator will review all new PRN psychotropic orders for a 14 day stop date. Audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.