Failure to Limit and Reevaluate PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to limit the duration of a PRN psychotropic medication order to 14 days or document a specific duration and rationale for extending the order, as required by regulation. Resident #36, admitted with an anxiety disorder and diagnosed with colon cancer, was under hospice care and severely cognitively impaired, with no documented behaviors or rejection of care on the most recent MDS. On 5/9/25, the physician ordered Lorazepam Intensol 2 mg/ml, 1 ml via PEG tube every 2 hours PRN for anxiety. This PRN Lorazepam order, a psychotropic and controlled substance, remained active in the EMR from 5/9/25 through at least 12/17/25 without a documented stop date or specified duration beyond the initial order. Review of the MARs showed that the resident received two to three doses of PRN Lorazepam weekly from 5/9/25 through 12/17/25, with the last documented dose on 12/16/25. Nurse #1 and the hospice nurse both reported that the resident experienced agitation and anxiety during care and received PRN Lorazepam multiple times per week. The hospice nurse stated that hospice medications were reviewed every two weeks by the hospice interdisciplinary team, but the facility physician was responsible for writing and managing all medication orders and could accept or decline hospice recommendations. The interim DON, former Medical Director, and current Medical Director each acknowledged that PRN psychotropic medications should include a stop date, be reviewed within the regulatory timeframe, and have a documented rationale and specified duration, confirming that these requirements were not met for this resident’s ongoing PRN Lorazepam order.
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