Failure to Implement Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, Lorazepam, prescribed for anxiety and restlessness, had a required 14-day stop date for a resident who was severely cognitively impaired and receiving hospice care. Despite multiple monthly drug regimen review consultation reports from the Consultant Pharmacist recommending discontinuation or the addition of a stop date, the Lorazepam order remained active without a stop date for several months. The physician initially accepted the pharmacist's recommendation but did not specify a stop date, and subsequent recommendations were either not implemented or declined with the rationale that the resident was on hospice care. Interviews with nursing staff and the DON revealed a misunderstanding among staff that hospice residents were exempt from the requirement for PRN psychotropic medication stop dates. The DON was unaware of this belief among staff and was not aware that the medication order lacked a stop date. The Administrator also believed hospice residents should continue their psychotropic medications but acknowledged awareness of the regulatory requirement for stop dates on PRN psychotropic medications.