Lack of Documented Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
Facility staff failed to ensure that a clinical rationale was documented for the continued use of a PRN (as needed) antianxiety medication for one resident. The facility's policy requires that PRN psychotropic medication orders be time-limited, with extensions beyond 14 days only permitted if the prescriber documents a clinical rationale, including effectiveness, ongoing diagnosis, indication, and duration. For the resident in question, who had diagnoses including delirium, major depressive disorder, psychosis, unspecified mood disorder, senile degeneration of the brain, and Alzheimer's disease, a PRN order for lorazepam was continued for six months without the required documentation of rationale by the provider. Record reviews showed that the resident had severe cognitive impairment and was receiving antipsychotic and antidepressant medications, but did not display behaviors according to the MDS. The pharmacist recommended continuation of the PRN lorazepam, and the provider agreed, but failed to document the necessary clinical rationale for its continued use. The DON confirmed during interview that no rationale was documented for the ongoing PRN lorazepam order.