Failure to Discontinue PRN Psychotropic Medication Orders After 14 Days
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic drug use, specifically regarding PRN Lorazepam orders that were not discontinued after 14 days as required by federal regulations and the facility's own policy. For one resident, the Lorazepam PRN order was initiated for anxiety and restlessness, with the order specifying an 'indefinite' stop date. Upon review, the Registered Nurse Supervisor confirmed that the order should have been discontinued after 14 days, but it remained active beyond this period without appropriate physician documentation or review. Another resident had a similar issue, with a PRN Lorazepam order for anxiety that also had an 'indefinite' stop date. The order was not discontinued after 14 days and was only changed months later when the frequency was increased, but the new order again lacked a stop date. The Registered Nurse Supervisor and the Director of Nursing both verified that the PRN Lorazepam order should have been limited to 14 days, and there was no written documentation from the physician to justify extending the order beyond this period. Both residents had significant cognitive impairments and required extensive assistance with activities of daily living. Their medical records indicated diagnoses such as dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder. The facility's policy on psychotropic medication use, revised in February 2025, clearly stated that PRN orders for psychotropic medications are limited to 14 days, yet this policy was not followed in these cases.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 85 Hospice Physician was alerted and new order placed for Lorazepam 2mg/ml q 4 hrs as needed for anxiety on 6/12/2025 to include a 14 day stop date. See Written Education with Compliance Cue to support 1:1 with DON. Immediate Corrective Action for resident affected by this deficient practice: Resident 86 Lorazepam was discontinued on 2/17/2025. Renewed on 6/24/2025 by Hospice Physician. Give Lorazepam 1 mg q 2 hours PRN x 14 days for anxiety. See Written Education with Compliance Cue to support 1:1 with DON. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: Resident 86 Hospice N/P and Resident 85 Hospice Physician have received a 1:1 in-service by DON on 7/4/2025 regarding Compliance Cue (New Regulation) to provide written documentation extending a PRN psychotropic drug if deemed necessary or need to limit to 14 days. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: DON added new Template Program labeled: Order Listing Report, to monitor PRN Psychotropic drug to include active PRN Psychotropic drug and DON and/or designee will run daily. Included instructions to audit PRN psychotropic drugs. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings to ensure total compliance is achieved. Monthly QA discussion will occur for 3 months. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: DON added new Template Program labeled: Order Listing Report, to monitor PRN Psychotropic drug to include active PRN Psychotropic drug and DON and/or designee will run daily. Included instructions to audit PRN psychotropic drugs. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings to ensure total compliance is achieved. Monthly QA discussion will occur for 3 months.