Failure to Timely Review PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication prescribed to a resident was reviewed by a practitioner for necessity and appropriateness within 14 days, as required. The resident, who had diagnoses including hemiplegia, major depressive disorder, adjustment disorder with anxiety, and vascular dementia, was admitted with severe cognitive impairment. The care plan identified the potential for adverse effects from antianxiety medications and included interventions for administering and monitoring these medications. A PRN order for Vistaril 25 mg every six hours for anxiety or agitation was initiated without a specified duration. Despite a pharmacy recommendation to review the PRN psychotropic order after 14 days, the physician did not review or address the order until over a month later. During this period, the medication was administered on two occasions. The facility's policy required practitioner review and documentation of rationale for continuing PRN psychotropic medications beyond 14 days, but this was not followed. The DON confirmed that the required review was not completed within the specified timeframe.
Plan Of Correction
Resident #33 was immediately assessed and found to have no adverse effects. All residents on a PRN antipsychotic medication have the ability to be affected. All residents on PRN antipsychotic orders were immediately audited by DON/designee to ensure all had stop dates in place. Education on antipsychotic usage, GDR process, and appropriate orders was provided by the DON to all nursing staff on 5/22/25. DON/designee to audit all PRN antipsychotic orders for stop date weekly for 4 weeks. Results to be reviewed in QAPI. Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS assessments on 5/22/25 to ensure they were complete. Resident #22’s annual MDS assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.