Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as needed (PRN) psychotropic medication, lorazepam, prescribed for a resident with anxiety, included a required stop date of 14 days as per regulations. The resident, who had a diagnosis of anxiety and severely impaired cognition, was readmitted to the facility and had a physician's order for lorazepam 0.25 mg every 8 hours PRN for anxiety, but the order did not specify a stop date. Review of the resident's medication administration records showed that the medication remained active and was administered multiple times over two months without a stop date. Interviews with the Nurse Practitioner revealed that she typically wrote PRN psychotropic medication orders for 14 days and then evaluated the resident's need, but in this case, she usually wrote the lorazepam order for 30 days due to the resident's behaviors. However, she was unaware of why there was no stop date on the order in the system. The Director of Nursing acknowledged awareness of the requirement for a physician-designated stop date for PRN psychotropic medications and stated that staff were educated on this, but indicated that the lack of a stop date for this resident's lorazepam was an oversight.