Failure to Limit PRN Psychotropic Use and Ensure Appropriate Diagnosis
Penalty
Summary
The facility failed to limit the use of a PRN psychotropic medication, specifically Lorazepam, to the required 14-day period and did not ensure that the resident receiving the medication had an appropriate diagnosis. Clinical record review showed that the resident had intact cognition, no diagnosis of anxiety or other mood disorders, and no behavioral or depressive symptoms, yet received Lorazepam regularly over several months. The medication was administered almost daily, far exceeding the 14-day limit for PRN psychotropic use without documented physician rationale for extension. Additionally, the facility did not respond to repeated recommendations from the consulting pharmacist to review and address the ongoing PRN Lorazepam order in accordance with the 14-day rule. The electronic health record lacked documentation of a physician's evaluation or justification for continued use, and the facility's Medication Regimen Review policy, which requires forwarding pharmacist findings to the physician, was not followed. Both the DON and the Administrator acknowledged the absence of an appropriate diagnosis and the failure to act on pharmacy recommendations.