Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications. For two residents with severe cognitive impairment and diagnoses including generalized anxiety disorder and dementia, PRN orders for Lorazepam were not limited to 14 days as required, nor was there consistent documentation of a physician’s rationale for extending the orders beyond this period. In one case, a pharmacy consultant recommended a 90-day continuation, but this was not reflected in the physician’s order, and in another, there was no documented response to the pharmacy consultant’s recommendation. Record reviews showed that one resident received Lorazepam on several occasions without a 14-day stop date, and the medication administration records did not consistently align with the required documentation. Additionally, care plans did not always address the use of PRN psychotropic medications, and there was a lack of progress notes detailing the administration or monitoring of these drugs. Staff interviews revealed a lack of awareness and formal training regarding the 14-day stop date requirement, and there was no established system in place to monitor compliance with this regulation. Interviews with facility staff, including the DON, ADON, and administrative staff, confirmed that they were unaware of the missing 14-day stop dates and had not implemented a process to ensure compliance. The staff acknowledged the requirement and the facility’s policy but indicated that responsibility for ensuring the stop date was unclear, especially when medications were ordered by hospice or outside providers. The deficiency was further compounded by inconsistent communication and documentation between the facility, pharmacy consultant, and prescribing practitioners.