Lack of Documentation for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the medical record contained documentation demonstrating the rationale for extending a PRN (as needed) psychotropic medication order for a resident. Specifically, a resident with chronic respiratory failure had a PRN order for hydroxyzine for anxiety, which was later changed to a scheduled dose, and subsequently, clonazepam was started as a PRN medication for anxiety. The clonazepam PRN order was extended beyond the initial 14-day period without documentation from the prescribing practitioner explaining the medical necessity for this extension in the resident's medical record. Review of the resident's records showed that the medication was administered as ordered, and observations confirmed the resident was sleeping after receiving the medication. During interviews and record reviews with the DON, it was acknowledged that the required documentation for the rationale behind the continued PRN use of clonazepam was missing, which was not in accordance with the facility's own policy on psychoactive drug monitoring. The policy requires that the medical necessity for psychoactive medications be documented and regularly reassessed, with any continuation clearly indicated in the medical record.