Failure to Include Required 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications, as required by facility policy and regulations. Specifically, a resident with diagnoses of post-traumatic stress disorder (PTSD) and anxiety disorder had a physician order for PRN (as needed) Klonopin (clonazepam) to treat anxiety. The order, dated June 30, 2025, did not include a required 14-day stop date or documented rationale for extending the PRN use beyond 14 days, as stipulated in the facility's policy for psychotropic medications. Review of the resident's medication administration records for three months showed that no doses of Klonopin were administered. During staff interviews, it was revealed that the facility's electronic health record system classified clonazepam as an anticonvulsant rather than a benzodiazepine, which resulted in the system not flagging the order for the required 14-day stop date. Staff acknowledged that the 14-day stop date should have been included since the medication was being used to treat anxiety.