Failure to Ensure 14-Day Stop Date or Justification for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a 14-day stop date or a physician's justification for continuation was in place for an as-needed (PRN) psychotropic medication prescribed to a resident. The resident, who had diagnoses including schizophrenia, cerebral edema, and adjustment disorder with anxiety, had an order for PRN clonazepam for sleeplessness and anxiety without a specified stop date or documented rationale for use beyond 14 days. Review of the resident's electronic health record and medication administration records confirmed the absence of a stop date or physician justification for the ongoing PRN order, despite facility staff acknowledging that such medications should have a 14-day limit unless otherwise justified. Observations of the resident showed them in various settings within the facility, and interviews with nursing and administrative staff confirmed the lack of compliance with the 14-day stop date requirement for PRN psychotropic medications. The facility was unable to provide a policy regarding 14-day stop dates for psychotropic medications. This deficiency was identified through record review, staff interviews, and direct observation, and it placed the resident at risk of unnecessary psychotropic medication use and related adverse effects.