Failure to Monitor Psychotropic Medication Use and Lapse in PRN Order Management
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were properly monitored and that as-needed (PRN) psychotropic medication orders included required end dates, as outlined in facility policy. For multiple residents, including those with severe cognitive impairment, Alzheimer's disease, depression, psychotic disorder, and other significant medical conditions, there was a lack of documented assessments for extrapyramidal symptoms (EPS) using the Abnormal Involuntary Movement Scale (AIMS) or similar tools, as well as missing orthostatic blood pressure monitoring. These assessments are necessary to monitor for side effects of antipsychotic medications, such as tardive dyskinesia and orthostatic hypotension, but records showed that these were not completed as required by policy and physician orders. Additionally, the facility did not ensure that PRN psychotropic medication orders, such as lorazepam, clonazepam, and buspirone, included stop dates or were limited to 14 days as required by the facility's psychotropic medication policy. In several cases, PRN orders remained active without an end date, and there was no documentation of physician evaluation or rationale for extending the orders beyond the policy limit. Interviews with nursing staff and the DON confirmed that these omissions were not in line with facility expectations and policy requirements. The deficiencies were identified through review of medical records, care plans, medication administration records, and staff interviews. The lack of required monitoring and documentation for residents prescribed antipsychotic and other psychotropic medications, as well as the absence of stop dates for PRN orders, constituted a failure to prevent unnecessary medication use and to monitor for adverse effects, as required by both facility policy and standard clinical practice.