Failure to Ensure Proper Use and Documentation of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications, as evidenced by the clinical records of two residents. For one resident with chronic respiratory failure, multiple sclerosis, and cognitive communication deficit, there was a physician's order for PRN Clonazepam to be administered for anxiety/insomnia, but there was no documented diagnosis of anxiety or insomnia in the clinical record. Additionally, the PRN order for Clonazepam was set with an indefinite stop date, contrary to facility policy requiring PRN psychotropic medications to be limited to 14 days unless a clinical rationale for extension is documented. Another resident with chronic respiratory failure, anoxic brain damage, and dysphagia had a physician's order for PRN Ativan to be given for teeth grinding, but there was no documented diagnosis of teeth grinding in the clinical record. This PRN order for Ativan also had an indefinite stop date. The facility did not ensure that psychotropic medications were used to treat a specific, documented condition and did not comply with the policy limiting PRN psychotropic medication orders to 14 days or requiring documentation of rationale for continued use.