Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not limiting the use of as-needed (PRN) psychotropic medications to 14 days, as required by facility policy. Record review showed that a resident with diagnoses including cerebrovascular disease, hemiplegia, malnutrition, vascular dementia, and unspecified psychosis had a physician order for Ativan 0.5 mg to be given every four hours as needed for anxiety or dyspnea, starting on 04/25/25. The order did not include a stop date and was not limited to 14 days, contrary to facility policy and regulatory requirements. The resident's care plan indicated a history of aggression and resistance to care, with interventions to administer medications as ordered and monitor behaviors and side effects. The Minimum Data Set assessment documented significant cognitive impairment. During an interview, the DON confirmed that the PRN Ativan order should have had a stop date and should not have been ordered for more than 14 days. Facility policy on psychotropic medication management also specified that PRN psychotropic medications are to be limited to 14 days unless otherwise justified.