Failure to Address PRN Psychotropic Medication Use in QAPI Program
Penalty
Summary
The facility failed to utilize its Quality Assurance Performance Improvement (QAPI) program to address the use of PRN psychotropic medications for its residents. Specifically, the facility did not collect data or identify corrective measures for PRN psychotropic medication use that lacked a stop date or a documented rationale for ongoing use in the affected residents' medical records. This deficiency was identified for a census of 57 residents, and the lack of documentation and justification for ongoing PRN psychotropic medication use was confirmed during interviews and record reviews with the Director of Nursing (DON) and the Administrative Director (ADM). The DON confirmed that although the previous survey's plan of correction required PRN psychotropic medication use to be monitored through the QAPI program and reviewed monthly by the pharmacist, these measures were not implemented. The DON and ADM both acknowledged that the corrective actions were not added to the QAPI program as required, and the issue was not addressed due to the committee's focus on other areas. The facility's policy required all deficiencies from previous surveys to be added to QAPI, but this was not followed, resulting in the recurrence of the problem.