Pharmacist Failed to Identify Prolonged PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified and addressed the prolonged use of an as-needed (PRN) psychotropic medication for a resident. Review of the resident's physician orders showed a PRN order for Lorazepam oral concentrate, to be given every 8 hours as needed for anxiety, with no stop date indicated. The order was active from November 2024 through April 2025. Monthly medication regimen reviews conducted by the pharmacist for December 2024 through March 2025 did not identify any significant irregularities for this resident, despite the ongoing PRN order for a psychotropic medication. During an interview, the pharmacist responsible for the medication regimen reviews stated that she reviews progress notes, vital signs, labs, physician's orders, and assessments, and is aware that psychotropic medications should be minimized and PRN orders are generally limited to 14 days unless otherwise documented by the physician. However, she was unsure how she missed the prolonged PRN lorazepam order for multiple months. Facility policy requires that PRN psychotropic medications be limited to 14 days unless the physician documents a rationale and duration for continued use, which was not present in this case.