Failure to Time-Limit PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from chemical restraints and to limit PRN psychotropic medications to 14 days as required. Record review for Resident #2, who was re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, diabetes, late syphilis, and unspecified dementia with behavioral symptoms, showed a physician’s order dated 10/03/2024 for Oxazepam 15 mg PO PRN every 24 hours at night for insomnia without a discontinue date. The Pharmaceutical Consultant Report dated 10/13/2025 documented that PRN psychotropic medications must be limited to 14 days, with the prescriber required to evaluate the resident before extending the order, document the rationale for any extension, and indicate a specific duration. The report further showed that the physician did not indicate a specific duration for this PRN Oxazepam order, and during interview the DON confirmed that the physician had not specified a duration for the psychotropic PRN order. This failure to include a time-limited duration and required evaluation for the PRN psychotropic medication order for Resident #2 resulted in noncompliance with requirements intended to prevent unnecessary psychotropic use and chemical restraint.
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