Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) orders for psychotropic drugs were limited to 14 days, as required by regulations. Specifically, for one resident, an as needed antianxiety medication, Ativan, was ordered for periods longer than 14 days without documented physician rationale to extend the duration of the order. The facility's policy on psychotropic medication use mandates that such medications are not prescribed on an as needed basis unless necessary for a diagnosed condition, and any extension beyond 14 days must be justified and documented by the prescriber. Resident #24, who had diagnoses including traumatic brain injury, anxiety disorder, and dementia, was cognitively intact and had no behavioral symptoms according to the Minimum Data Set. Despite this, the resident received multiple as needed orders for Ativan over an extended period without the required 14-day reevaluation and documentation of rationale for continuation. Observations and interviews with staff indicated that the resident's anxiety was stable, and there were no recent behavioral issues, suggesting that the extended use of Ativan may not have been necessary. Interviews with various staff members, including the Nurse Practitioner, Consultant Pharmacist, Medical Director, and Registered Nurse Supervisors, revealed a lack of awareness and oversight regarding the 14-day limitation for as needed psychotropic medications. The Consultant Pharmacist and Medical Director acknowledged the oversight, and the Social Worker confirmed that the as needed Ativan order was incorrectly set for 30 days instead of 14. The Director of Nursing and other staff noted improvements in the resident's condition, further questioning the need for prolonged use of the medication without proper documentation and review.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 483.45(e)(4) [MEDICAL CONDITION] Drugs 1. The facility currently has [MEDICAL CONDITION] Medication Use policy that ensures residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is deemed necessary to treat a diagnosed specific condition that is documented in the clinical record. Resident #24's chart was reviewed by the Medical provider and PRN [MEDICAL CONDITION] order was discontinued, and a corrected PRN [MEDICAL CONDITION] order was written immediately with stop date of 14 days. Two (2) separate audits by the Director of Nursing and Pharmacy Consultant on 3/19/25 were completed to ensure [MEDICAL CONDITION] medication use accuracy in all medical records. Audits will continue twice per month for the next 6 months. 2. Nursing Staff were educated immediately by the Director of Nursing with an in-service reviewing Policy and Procedure, Continuing education regarding [MEDICAL CONDITION] Medications and PRN Medication Administration. RN and LPN staff completed this in-service by 3/25/2025. The Director of Nursing, Pharmacist Consultant and Social Worker meet once monthly to review resident [MEDICAL CONDITION] use. All residents are reviewed monthly/quarterly and as needed. Residents that need GDRs are determined and reviewed by the Director of Nursing/designee and Medical Director. 3. The Director of Nursing reviewed all Resident Care plans for [MEDICAL CONDITION] drug use. As stated in our [MEDICAL CONDITION] Medication Use policy, residents will not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days except if the attending physician/designee believes that it is appropriate for the PRN order to be extended beyond 14 days. The Physician/designee will document any clinically contraindicated or specific conditions in clinical record along with their rationale and indicate the duration for the PRN order. 5. All (52) current resident’s medical records were audited to ensure all active PRN [MEDICAL CONDITION] medications have a 14-day stop date. If the order does not include the 14-day stop date, prescriber will be contacted and a corrected order will be issued. If the prescriber deems it appropriate to extend past 14 days, the prescriber will document rationale in the resident’s permanent medical record. An audit of the clinical record for PRN [MEDICAL CONDITION] Medications will continue twice monthly x 6 months by the DON/designee and/or Pharmacy Consultant. All audits will be reviewed quarterly for the next 6 months at QA/QAPI meetings. The Director of Nursing/designee will be responsible for the overall implementation of the plan of correction.