Failure to Ensure Proper Documentation and Duration for PRN Psychotropic Medication
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's dementia, major depressive disorder, and anxiety disorder was administered lorazepam (Ativan) without proper indication for use and without a documented discontinuation date. The resident was dependent on staff for activities of daily living and was receiving hospice and comfort-directed care. The physician's order requested continuation of lorazepam for anxiety and agitation, but did not specify an end date. The order was entered into the electronic health record by the DON as a PRN medication to be given every four hours as needed until a specified date, but this did not align with the original physician's order. Facility policy required that PRN psychotropic medications not be continued beyond 14 days unless the prescriber documented the rationale and specified the duration. Review of the records showed no documentation from the prescriber justifying the extension or specifying the number of days for continued use. The DON relied on the pharmacist's monthly review as justification, but the review did not address the lorazepam order. Additionally, a reference document provided by the pharmacist clarified that there is no exception to the 14-day rule for comfort care or hospice orders, yet the required documentation was still not present.