Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychotropic medication, Lorazepam, prescribed for a resident with anxiety and depression, included a required 14-day stop date. The medication order was entered by a nurse upon the resident's readmission, but no stop date was specified. Review of the resident's medication administration record showed that the order for Lorazepam remained active throughout the month, although no doses were administered. The resident was cognitively intact, displayed no behaviors or rejection of care, and did not receive any antianxiety medication during this period. Interviews with facility staff revealed that providers had recently begun entering their own orders and often omitted stop dates for medications when indicated. The DON acknowledged that the order should have included a 14-day stop date and that the admitting nurse had an opportunity to clarify this with the provider during order verification. The facility had a standing policy to discontinue unused medications after 60 days, but this did not align with the specific requirement for a 14-day stop date for PRN psychotropic medications.