Failure to Document Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychotropic hypnotic medication for insomnia was limited to 14 days or to an appropriate time frame approved by the provider for one resident. Record review showed that the facility did not have a policy on stop dates for psychotropic drugs. A resident had an order for Zolpidem 5 mg PRN for insomnia, and the consultant pharmacist recommended extending the order for six months, which the physician approved. However, this approved stop date was not entered into the resident's orders by facility staff. Interviews with the RN/MDS Coordinator and the DON confirmed that PRN psychotropic medications should have a 14-day stop date or a longer period if approved by the physician. Both acknowledged that the pharmacist's recommendation and the provider's approval for a six-month extension were overlooked and not documented in the resident's orders. As a result, the required stop date for the PRN hypnotic psychotropic medication was missing for a resident admitted with a diagnosis that included insomnia.