Failure to Report and Act on Medication Irregularity for Psychotropic PRN Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a medication irregularity identified during the monthly Medication Regimen Review (MRR) was reported to the resident's primary physician in accordance with facility policy. The irregularity involved a psychotropic medication, lorazepam, prescribed as needed (PRN) for a resident with diagnoses including dementia, major depressive disorder, and anxiety disorder. The facility's policy and federal regulations require that PRN orders for psychotropic medications be limited to 14 days unless the physician documents the rationale for extending the order in the clinical record. The MRR conducted in February identified that the PRN lorazepam order should be limited to 14 days, and this recommendation was documented by the pharmacy consultant. However, the order for lorazepam, initiated in February, was not discontinued after 14 days and remained active without a stop date until June, when the frequency of administration was changed. There was no written documentation from the physician to justify extending the PRN order beyond 14 days, and the new order also lacked a stop date. The pharmacy consultant stated that the recommendation was made only once and not repeated in subsequent monthly reviews, while the DON confirmed that the recommendation was not followed and the physician was not made aware of it. The failure to act on the pharmacist's recommendation and to communicate the irregularity to the physician resulted in the continued administration of lorazepam without proper review or documentation. This was contrary to both facility policy and federal requirements, which mandate that such irregularities be reported and acted upon to ensure appropriate medication management for residents.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: 1:1 Inservice given to DON on 07/01/25 by Pharmacist Physician regarding regulation and policy of Psychotropic Drugs to include end date for PRN medications of 14 days. Also, pharmacist to review Drug Regimen Review Report monthly. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON evaluated all Residents and educated 2 Separate Hospice Physician/Resident N/P regarding regulations and policy on PRN Psychotropic Drugs to include 14 day end dates or to justify necessity to continue psychotropes or discontinue. No other residents were found for the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: All licensed Nurses were inserviced on 06/16/25 with DON and DSD with Pharmacist Consultant new audit tool to include PRN Psychotropic Drugs to have a 14 day end date. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Starting 7/01/25, the DON and or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.