Failure to Reassess PRN Psychotropic Medication Order After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not reassessing a PRN (as needed) order for trazodone after 14 days, as required by facility policy. The policy states that PRN orders for psychotropic medications, excluding antipsychotics, must be reassessed after 14 days, and if continued, the physician must document the rationale and specify the duration. In this case, a resident with Alzheimer's Disease and adjustment disorder, who had severe cognitive impairment, was prescribed PRN trazodone for anxiety without a stop date. The medication administration records showed that the resident received PRN trazodone 19 times over several months, but there was no documentation in the physician or nurse practitioner notes indicating that the order was reassessed or that a reassessment date was added. Interviews with nursing staff and the DON confirmed that all PRN psychotropic medications should be reassessed after 14 days and have an end or reassessment date, but this was not done for the resident in question.