Failure to Specify Duration and Rationale for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) antianxiety medication, Ativan (lorazepam) cream, had a 14-day stop date or a specified duration with a physician's rationale for ongoing use. The resident, who had diagnoses of anxiety, dementia, and major depressive disorder, was noted to have severely impaired cognition and required extensive assistance with activities of daily living. The care plan indicated the resident received antianxiety medication and mental health consults, but the physician's order for Ativan cream lacked a stop date or documented rationale for continued PRN use. Observations showed the resident exhibiting agitation and resistance to redirection, leading to the administration of Ativan cream by staff. Review of the electronic medical record confirmed the absence of a specified duration or physician rationale for the extended use of the PRN medication. Administrative staff verified that the required stop date or justification for continued use was not obtained, which was inconsistent with the facility's policy on antipsychotic medication use that requires periodic reassessment and documentation.