Failure to Limit PRN Antipsychotic Orders to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not adhering to the required 14-day limitation for as needed (PRN) antipsychotic medication orders. Specifically, the resident, who had a diagnosis including visual hallucinations and moderate cognitive impairment, received PRN orders for Seroquel that were written for durations exceeding 14 days on multiple occasions. Medical record review showed that these PRN Seroquel orders were written for 30, 60, and other periods longer than the allowed 14 days, contrary to regulatory requirements. Interviews with facility staff, including a physician, nurse practitioner, and the DON, confirmed that the PRN Seroquel orders should have been limited to 14 days but were not. The physician stated he was unaware that antipsychotic PRN orders could not exceed 14 days without exception, and both the nurse practitioner and DON acknowledged that the orders were not compliant with the 14-day limitation. This resulted in the resident receiving PRN antipsychotic medication orders for extended periods without the required limitation and evaluation.