Failure to Discontinue PRN Psychotropic Medication Order Within Required Timeframe
Penalty
Summary
The facility failed to discontinue an as-needed (PRN) order for a psychotropic medication, Haldol Decanoate, beyond the allowable fourteen-day period for one resident. A review of the resident's physician orders showed an order for Haldol Decanoate 50 mg/mL to be administered intramuscularly as needed for agitation and aggressive behavior, with a maximum of 100 mg per month. This PRN order was not discontinued after fourteen days as required, despite the resident not receiving any PRN doses during the review period. The facility's policy and interviews with the nurse practitioner, pharmacy consultant, and DON confirmed that such orders must be discontinued after fourteen days unless a physician conducts a physical evaluation and rewrites the order. The resident involved had diagnoses of schizophrenia and major depressive disorder and was cognitively intact, as indicated by a BIMS score of 15. The oversight was acknowledged by the DON as a human error, and it was confirmed that both the DON and the charge nurse are responsible for ensuring timely discontinuation or renewal of such orders. The deficiency was identified through observation, interview, and record review, and was not associated with any administration of the PRN medication during the period in question.