Failure to Adhere to 14-Day Limit for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure compliance with the 14-day limit for as needed (prn) psychotropic medication use, specifically Haldol, for one resident receiving palliative care. The resident's physician order set included a prn Haldol order for agitation without a stop date or documented clinical rationale for continued use beyond the required timeframe. Review of the treatment administration record showed that after the 14-day limit had passed, the resident received 17 additional doses of prn Haldol without a provider evaluation or documentation supporting the ongoing need for the medication. An interview with the Nurse Manager/Supervisor confirmed the absence of required documentation and provider review regarding the continued administration of prn Haldol, and the provider's progress notes did not address the medication's use during a subsequent visit. The deficiency centers on the lack of timely provider evaluation and documentation for the continued use of a psychotropic medication beyond regulatory limits, as well as the administration of multiple doses after the required review period had expired.