PRN Psychotropic Medication Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure that a PRN (as needed) psychotropic medication, lorazepam, prescribed for a resident with anxiety disorder, included a required 14-day stop date as per CMS guidelines. The resident, who had severely impaired cognition and a history of anxiety, was admitted with both scheduled and PRN orders for lorazepam, both entered by the Medical Director without a stop date for the PRN order. Review of the medication administration records showed that the PRN lorazepam order remained active for over a month without being administered, even after the resident was started on a scheduled lorazepam regimen. Staff interviews revealed that nursing staff were aware of the ongoing PRN lorazepam order and the requirement for a 14-day stop date for PRN psychotropic medications. However, the nurse involved believed the rules may have changed when she noticed the missing stop date. The DON and Administrator both confirmed that the PRN lorazepam order should have included a 14-day stop date and attributed the oversight to the Medical Director and Consultant Pharmacist, rather than a systemic failure.