Lack of Documentation for PRN Psychotropic Medications
Penalty
Summary
The facility failed to document the rationale for the continued use of PRN anti-anxiety medications for three residents who were on psychotropic medications. Resident 47, diagnosed with anxiety, major depressive disorder, and end-stage renal disease, was administered Ativan PRN multiple times from January to March 2025 without documentation from the physician to extend the PRN order beyond 14 days. Similarly, Resident 106, with peripheral vascular disease, diabetes mellitus, and bipolar disorder, received Ativan PRN several times from January to February 2025, again without the necessary documentation for extending the PRN order. Resident 128, who had major depressive disorder, metabolic encephalopathy, Parkinson's disease, type 2 diabetes mellitus, anxiety, and unspecified dementia, was administered Ativan gel PRN numerous times from November 2024 to March 2025. Additionally, this resident received lorazepam PRN frequently from January to March 2025. In both cases, there was no documentation from the physician to justify extending the PRN orders beyond the initial 14 days. The facility's administrator confirmed the lack of documentation to support the rationale for extending these PRN psychotropic medications.
Plan Of Correction
1. Orders for resident 47, resident 106, and resident 128 were reviewed by the physician and end dates for PRN psychotropic medications were applied on 3/6/25. 2. DON/ADON will audit all PRN psychotropic medication orders to ensure end dates are in place. 3. DON or Designee will educate nurses on PRN end dates and reassessment after 14 days. Education will be given to provider to document rationale for any continuation for PRN psychotropic medication. 4. DON or designee will complete audit on PRN psychotropic medication orders weekly x3, and monthly x2. Results will be presented at QAPI.