Failure to Act on Pharmacist's Recommendations for PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly drug regimen review were acted upon by the attending physician for one resident. Specifically, the pharmacist noted that the resident had a PRN order for Lorazepam that exceeded 14 days without a documented stop date or a rationale for extending the use or duration of treatment. Despite the pharmacist's recommendation to add a stop date and, if necessary, document the indication, intended duration, and rationale for continued use, there was no evidence in the resident's medical record that these requirements were met. The resident involved had multiple diagnoses, including palliative care, vascular dementia, cognitive communication deficit, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. Multiple Lorazepam orders were initiated and discontinued over several months, with at least one order lacking the required documentation for extended PRN use. Although a handwritten note on the pharmacy report indicated a stop date was in place, the medical record did not contain the necessary documentation to support the extended use of Lorazepam as required by CMS guidelines.