Failure to Discontinue PRN Medication as per Policy
Penalty
Summary
The facility failed to reevaluate or discontinue a PRN order for guaifenesin oral liquid for a resident after 10 days, as required by the facility's policy. The resident, who was admitted with diagnoses including anxiety disorder and had a history of worsening functional and cognitive decline, was prescribed guaifenesin to be taken every four hours as needed for congestion. However, the order did not specify a stop date, and the medication continued to be available beyond the 10-day limit set by the facility's policy. The consultant pharmacist had recommended that the facility indicate the length of therapy for the PRN guaifenesin, in line with the policy that limits cough and cold products to 10 days. Despite this recommendation, there was no apparent response from the facility. During an interview, the Director of Nursing acknowledged the failure to limit the use of the medication as per policy, which increased the risk of the resident receiving the medication when it was no longer clinically appropriate. This oversight could have led to adverse effects and a decline in the resident's quality of life.
Plan Of Correction
2 residents had orders for guaifenesin oral liquid as needed. 0 of 2 residents were identified without a duration for use. 1 of 2 residents' orders were clarified and/or discontinued by the licensed nurse on 3/18/25. No other residents were affected by this deficient practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Medical Records will audit the physician orders for PRN medications monthly to ensure all as needed medications have a duration for use and include a stop date as part of the order. The Director of Nursing/designee will re-educate the nursing staff on or before, 3/21/2025, re: the facility's policy, "Physician Telephone Orders," with emphasis on ensuring orders are complete and include a stop date for as needed medications. The DSD orients new employees upon hire, annually and as needed on completion of physician orders including completing the order to include stop dates for as needed medications to treat temporary conditions. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Medical Records will audit physician orders for as needed medications monthly to ensure orders contain a stop or discontinue date. As needed orders identified without discontinuation or stop dates will be provided to the Director of Nursing for further review and correction. The Director of Nursing will report significant trends identified during review of the medical records monthly audit to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction; or for determination of substantial compliance and termination of this plan of correction. Substantial compliance will be demonstrated by three consecutive Quality Assurance reviews without variance to standard findings. Allegation of Compliance Date: 3/25/2025 F758 Free From Unnecessary Psychotropic Meds/PRN Use CFR(s): 483.45(c)(3)€(1)(5) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; 1. The IDT completed a gradual dose reduction assessment on Residents 1 and 71 on 2/28/2025. 2. The licensed nurse clarified Resident 101's use of Lorazepam PRN on 2/24/2025. 3. Resident 68's use of antipsychotic medication, Quetiapine, was discontinued on 1/29/25. 4. The licensed nurses are monitoring and documenting Resident 347's behaviors of "repetitive physical movements and restlessness" related to the use of PRN alprazolam. 5. Resident 347's simultaneous use of sertraline and escitalopram, both used to treat depression, was clarified by the licensed nurse on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents with psychotherapeutic medication therapy are potentially affected by the facility practice.