Failure to Limit PRN Antipsychotic Order and Respond to Pharmacist Recommendation
Penalty
Summary
The facility failed to respond to a consultant pharmacist's recommendation to limit a resident's PRN (as needed) order for Zyprexa, an antipsychotic medication, to a 14-day duration. The pharmacist made this recommendation on 3/23/25 after reviewing the resident's medication regimen, but the facility did not document any response or action taken regarding this recommendation. Review of the resident's Medication Administration Records (MAR) showed that the resident had active PRN orders for Zyprexa for periods exceeding 14 days, specifically from 3/6/25 to 3/30/25 (24 days) and from 3/31/25 to 4/16/25 (16 days). The resident had a history of bipolar disorder and schizophrenia and was assessed as having the capacity for medical decision-making. During an interview, the DON acknowledged that the facility did not limit the PRN Zyprexa order to 14 days as required and failed to respond to the pharmacist's recommendation. Facility policy requires that PRN antipsychotic orders be limited to 14 days and that any pharmacist recommendations be communicated to the physician with documentation of the rationale for medication changes. The facility's failure to follow these procedures resulted in the resident receiving PRN antipsychotic medication for longer than the policy allows, without documented physician evaluation or justification.