Failure to Update PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication use when an as needed (PRN) order for a psychotropic medication was not updated according to policy. Facility policy requires that PRN orders for psychotropic medications are limited to 14 days unless the prescriber documents a rationale for extending the order, including the duration. Review of the medical record showed that a resident with diagnoses of Dementia, Anxiety, and Depressive Disorder had a PRN order for Xanax, an antianxiety medication, dated 6/23/2025. There was no documentation of a new order or rationale for extending the PRN use beyond the 14-day limit as required by policy. During an interview, the DON confirmed that PRN psychotropic medication orders are only valid for 14 days and that a new order should be obtained if continued use is necessary. The DON acknowledged that no new order was given for the as needed Xanax after the initial order date, indicating a lapse in following the facility's policy for psychotropic medication management. This resulted in the resident receiving a psychotropic medication without proper ongoing clinical justification or updated physician order.
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