Pharmacist Failed to Identify 14-Day Stop Date for PRN Antianxiety Medication
Penalty
Summary
A deficiency occurred when the facility pharmacist failed to identify that a psychotropic medication, specifically an as needed (PRN) antianxiety medication (Compound: Ativan/Lorazepam Gel), required a 14-day stop date in accordance with facility policy. The medication was ordered for a resident with multiple diagnoses, including Alzheimer's disease, dementia, and adjustment disorder with mixed anxiety and depression. The resident was severely impaired in daily decision-making and exhibited disorganized thinking. Despite the facility's policy stating that PRN antipsychotic medications should not be renewed beyond 14 days without a healthcare practitioner evaluation, the medication was administered multiple times over several months after the initial 14-day period had passed. Pharmacy reviews conducted over several months did not identify the need for a 14-day stop date for the PRN antianxiety medication. The pharmacist explained that both the routine and PRN antianxiety medications were placed on the same prescription, which did not trigger a recommendation to discontinue the PRN medication after 14 days. As a result, the medication continued to be administered well beyond the policy's required stop date, and no pharmacy recommendation was made to the physician to address this issue.