Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medication orders were limited to 14 days as required by policy for one resident. The policy on the use of psychotropic medications specified that PRN orders should not exceed 14 days unless the prescriber documents a rationale for extending the order and specifies a duration. However, a review of the electronic medical record (EMR) for a resident with diagnoses including depression, anxiety, diabetes mellitus type 2, and urinary tract infection revealed an order for alprazolam 0.25 mg every 12 hours as needed for anxiety, with an indefinite stop date. The resident was cognitively intact, as indicated by a BIMS score of 15, and the care plan did not address the use of antianxiety or antidepressant medications. Medication administration records showed that alprazolam was administered multiple times beyond the 14-day limit set by policy, with doses given on several dates in both November and December after the initial order date. Staff interviews confirmed that PRN psychotropic medications are expected to be limited to 14 days, but the order in question was entered with an indefinite stop date by the Nurse Practitioner. Both the LPN and DON verified that the medication was administered outside the required timeframe, confirming the deficiency in following the facility's policy regarding PRN psychotropic medication orders.