Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a psychotropic medication, specifically Ativan (Lorazepam) gel, prescribed for a resident with Alzheimer's disease and other significant diagnoses, had a required 14-day stop date. The medication was ordered as an as-needed (PRN) controlled substance for agitation and anxiety, but the order did not include a 14-day limitation as mandated by facility policy and regulations. Despite the absence of a stop date, the medication continued to be administered to the resident on multiple occasions over several months. Record review showed that the medication was given repeatedly after the period it should have been discontinued, with administration dates spanning several months beyond the initial order. Interviews with both the Regional Clinical Support and the Director of Nursing confirmed that the facility did not follow its own policy or regulatory requirements regarding the 14-day stop for PRN psychotropic medications. The facility's policy clearly stated that such orders should not be renewed beyond 14 days without a healthcare practitioner's evaluation, which did not occur in this case.