Failure to Complete 14-Day Re-Evaluation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure timely follow-up for the initiation of a PRN psychotropic medication for one resident. Clinical record review showed that the resident, who had severe cognitive impairment and diagnoses including aphasia, autistic disorder, and profound intellectual disabilities, was prescribed Ativan as a PRN medication for anxiety and yelling. The physician's order for PRN Ativan did not include a stop date, and the medication was administered multiple times over a period exceeding 14 days. Documentation in the electronic health record did not show that the prescribing practitioner completed a required 14-day evaluation for the continued use of the PRN Ativan. The facility's policy on psychotropic drug use requires that PRN orders for such medications be limited to 14 days unless the practitioner documents a rationale for extending the order and specifies the duration. The policy also states that psychotropic medications should only be administered when necessary to treat a diagnosed condition and after non-pharmacological interventions have failed. Despite these requirements, the facility did not obtain or document the necessary 14-day re-evaluation for the continued use of PRN Ativan for the resident.