Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
A deficiency occurred when the facility failed to monitor and appropriately discontinue a psychotropic medication, lorazepam, prescribed as needed (PRN) for a resident with Alzheimer's disease, dementia with behavioral disturbance, and anxiety disorder. The resident, who had severely impaired cognition and an activated Power of Attorney, had an order for lorazepam 0.5 mg PRN every 6 hours for anxiety, irritability, and anger, starting on 2/25/25. According to the facility's policy, PRN orders for psychotropic medications are limited to 14 days unless the prescriber documents a rationale for extending the order. However, the order for lorazepam remained active without an end date and was not reviewed or discontinued after 14 days as required. Review of the resident's Medication Administration Record showed that lorazepam was administered multiple times over several months, indicating ongoing use beyond the 14-day limit. The Director of Nursing confirmed that the original PRN order was still active and had not been discontinued or reviewed as per policy. The oversight was identified during a survey, and the DON acknowledged that the PRN lorazepam order should have been discontinued after 14 days, as stipulated by facility policy.