Lack of Documentation for PRN Psychotropic Medication Use
Penalty
Summary
A resident with a history of anxiety disorder, vascular dementia, cerebral infarct, depressive disorder, dysphagia, and aphasia was prescribed PRN Hydroxyzine for anxiety without a documented rationale for extended use or a specific duration for its administration. The physician's order allowed for Hydroxyzine 25mg as needed twice daily, and the medication was administered on multiple occasions over a period of weeks. Upon review, surveyors were unable to locate any documentation in the resident's medical record that justified the ongoing use of the PRN psychotropic medication or specified how long it should be used. The Director of Nursing confirmed that there was no additional information available regarding the medication's use and that the facility did not have a specific policy or procedure for PRN psychotropic medications, instead referring to regulatory guidelines.