Failure to Obtain Required Rationale and End Date for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was only continued beyond 14 days with a provider’s written rationale and end date for one resident. The resident had moderate cognitive impairment, with a BIMS score of 10, and diagnoses including atrial fibrillation, cirrhosis, arthritis, and repeated falls. A new prescription dated 9/25/25 ordered Lorazepam 0.25 mg by mouth every 4 hours PRN for anxiety, and on 10/2/25 the order was changed to every 2 hours PRN without any documented rationale for continuing the PRN psychotropic or specifying an end date. The October MAR showed the PRN Lorazepam was administered 19 times through the 28th, with 11 of those administrations documented as ineffective. In an interview, the DON stated the family did not want the resident on psych medications and that staff tried all non-pharmacological interventions before administering medications per the family’s wishes, and acknowledged she did not think a rationale or end date was provided to continue the PRN Lorazepam, despite facility policy limiting PRN psychotropic use to 14 days unless extended by the physician with documented rationale.
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