R0012

Failure to Limit and Document PRN Psychotropic Medication Use and Non-Pharmacological Interventions

Maple Manor Rehab Center Of Novi IncNovi, Michigan Survey Completed on 03-06-2025

Summary

Two residents were found to have ongoing PRN (as needed) orders for anti-anxiety medications, specifically alprazolam and Xanax, without appropriate stop dates or documented clinical justification for extending the orders beyond 14 days. The facility's own policy, consistent with federal regulations, requires that PRN psychotropic medications be limited to 14 days unless the prescribing practitioner documents a rationale for extension and specifies a duration. In both cases, the orders were open-ended and lacked the required documentation from the prescribing practitioner to justify continued use beyond the 14-day limit.

Additionally, the medical records for both residents did not contain evidence that non-pharmacological interventions were attempted or documented prior to the administration of the PRN psychotropic medications. The facility's policy mandates that non-pharmacological approaches be used and documented before resorting to psychotropic medications unless clinically contraindicated. However, the Medication Administration Records (MAR) and nursing progress notes did not reflect any such interventions or monitoring of target behaviors before administering the medications.

Interviews with the Director of Nursing (DON) confirmed awareness of the requirements for stop dates and documentation of non-pharmacological interventions, but acknowledged that these were not followed in the cases reviewed. The lack of adherence to policy and regulatory requirements regarding psychotropic medication management and documentation led to the identified deficiencies.

Penalty

No penalty information released