Failure to Limit and Document PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to comply with requirements regarding the use of PRN (as needed) psychotropic medications for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. Specifically, the facility did not limit the duration of a PRN Xanax order to 14 days, nor did it ensure that the physician documented a rationale for extending the use of the medication beyond this period. The resident's medical record lacked evidence of physician re-evaluation or documentation supporting continued use of the PRN psychotropic medication after the initial 14-day period, despite repeated administrations over several weeks. Additionally, the facility did not document the behavioral symptoms that led to the administration of the PRN Xanax or any non-pharmacological interventions attempted prior to its use. Review of the electronic medical record, progress notes, and medication administration records did not reveal any such documentation. The facility's own policies required documentation of indications for psychotropic drug use, behavioral symptoms, and non-pharmacological interventions, but these were not followed in this case. The pharmacist's medication regimen review also did not address the ongoing PRN Xanax order.