Failure to Re-Evaluate PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the use of PRN lorazepam. According to the facility's policy, PRN orders for psychotropic medications, excluding antipsychotics, must be limited to 14 days unless the attending physician or prescribing practitioner provides documentation with a rationale for extending the order and specifies a duration. A resident who was readmitted with a hip fracture had a physician order for lorazepam every four hours PRN for agitation and anxiety. Review of the resident's medication administration records showed that lorazepam was administered multiple times over several months, exceeding the 14-day limit without any documented physician rationale or re-evaluation for the continued use of the medication. During interviews, staff confirmed that the required physician re-evaluation did not occur at the end of the 14-day period, and acknowledged that this step should have been completed.