Failure to Ensure PRN Psychotropic Medication Order Included Required Stop Date
Penalty
Summary
A deficiency occurred when the facility failed to identify and address an irregularity in the medication regimen review for a resident admitted with anxiety. The resident had a physician's order for lorazepam, an anti-anxiety psychotropic medication, to be administered every four hours as needed (PRN), but the order did not include a required stop date. The medication was administered frequently over several months, as evidenced by the Medication Administration Record, which showed the resident received lorazepam 31 times in March, 38 times in April, and 27 times in May. During an interview, the Pharmacy Consultant confirmed that the PRN lorazepam order lacked an end date and stated that a medication regimen review should have prompted a recommendation to the physician to include a 14-day stop date, in accordance with regulations. Facility policies reviewed indicated that PRN psychotropic medications require clear physician documentation for continued use and that monthly medication regimen reviews should identify medications that need to be tapered, discontinued, or changed. The failure to follow these procedures resulted in the resident potentially receiving unnecessary medication.