Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days unless the attending physician or prescribing practitioner documented the appropriateness of extending the order. A resident with severe cognitive impairment, anxiety disorder, Alzheimer's disease, diabetes, and major depressive disorder had multiple PRN orders for Lorazepam Oral Concentrate with indefinite end dates. These orders were not discontinued or reviewed for duration, and no documentation was provided to justify extending the PRN orders beyond 14 days. Interviews with the DON and QA Nurse confirmed that the PRN psychotropic medication orders lacked required stop dates and that staff were responsible for monitoring and auditing such orders. The QA Nurse acknowledged the oversight and indicated that the medication had not been discontinued because she was waiting for a response from the physician. The facility's policy required monthly reassessment of psychoactive medications, but this was not followed in the case of the resident.