Failure to Limit and Document PRN Psychotropic Medication Use
Penalty
Summary
A deficiency occurred when a resident with major depressive disorder and early-onset Alzheimer's disease, who was severely cognitively impaired, was prescribed Lorazepam (Ativan), an antianxiety medication, on an as-needed (PRN) basis. The physician's order allowed for administration of 0.5 mg every 4 hours as needed for anxiety. The order was initiated and remained active beyond the federally mandated 14-day limit for PRN psychotropic medications without documented physician rationale for extension or evidence of a required evaluation for continued use. Record review and interview with the Director of Nursing confirmed that the PRN Ativan order was not discontinued after 14 days, nor was there a documented reassessment or justification for its ongoing use. This failure to comply with federal regulations regarding the limitation and documentation of PRN psychotropic medication orders resulted in the cited deficiency.
Plan Of Correction
Element #4: The Director of Nursing and/or designee will review all new psychotropic PRN orders weekly for 12 weeks to verify duration limits and appropriate physician documentation. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025