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F0605
D

Failure to Discontinue PRN Psychotropic Medications After 14 Days

Forest Grove, Oregon Survey Completed on 07-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to discontinue PRN psychotropic medication orders after 14 days for one resident who was admitted with diagnoses of dementia and depression. The resident had physician orders for PRN psychotropic medications, including quetiapine fumarate, prochlorperazine maleate, and hydroxyzine HCl, but there was no evidence in the medical record that the physician documented a rationale for extending the use of these medications beyond 14 days or evaluated the continued need for them since admission. A pharmacy review later recommended discontinuation of the PRN psychotropics due to non-use. Additionally, a staff member stated she was unaware of the 14-day limitation for PRN psychotropic medications and acknowledged that the orders had continued past the required timeframe without proper physician evaluation or documentation.

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