Failure to Implement Pharmacist's PRN Psychotropic Medication Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to recommendations made by the consulting pharmacist and agreed upon by the medical director regarding a resident's PRN lorazepam order. The pharmacist's monthly medication regimen review identified that the PRN lorazepam order lacked a specified duration, as required by CMS regulations, and recommended that the prescriber document both the rationale for continued use and the duration of the PRN order in the medical record. The prescriber agreed with the pharmacist's recommendation and signed the form, but did not document the required rationale or specify the duration in the resident's medical record. Subsequent review of the resident's medical orders showed that the PRN lorazepam order remained active with an indefinite end date and no documented rationale or duration in the medical record. Interviews with the DON and Regional Director of Operations confirmed that, prior to surveyor intervention, there was no documentation in the medical record addressing the pharmacist's recommendation. The deficiency was identified for one resident reviewed for unnecessary medications during the facility's recertification survey.