Failure to Provide Clinical Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication beyond 14 days for one resident. According to facility policy, PRN orders for anti-psychotic medications are limited to 14 days and cannot be renewed without an evaluation by the attending physician for appropriateness. Review of the clinical record for a resident with diagnoses including anxiety, bipolar disorder, and hypertension showed an order for Ativan 0.5mg every eight hours as needed, which was administered multiple times over two months. However, the order lacked the required 14-day stop date or documented clinical justification for continued use beyond this period. The DON confirmed during interview that the necessary documentation and evaluation were not present.