Lack of Physician Documentation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the physician documented the clinical rationale and duration of use for a PRN (as needed) psychotropic medication prescribed to a resident with severe cognitive impairment. The resident was admitted with a diagnosis requiring psychotropic medication, specifically alprazolam for anxiety, but the Minimum Data Set (MDS) assessment did not indicate any coded behaviors. The electronic medical record showed that the PRN alprazolam order was initiated and continued, but there was no documentation from the physician regarding the clinical rationale or the intended duration of use for this medication. A pharmacist's medication regimen review specifically requested that the attending physician evaluate the diagnosis, behaviors, and usage patterns, and to document the rationale and duration for the PRN order, as required by facility policy. Despite this, the physician did not provide the necessary documentation in the resident's medical record. The facility's policy states that PRN psychotropic orders should not exceed 14 days unless the prescriber documents their rationale and the duration for continued use, which was not done in this case.