Failure to Limit PRN Psychotropic Medication to 14 Days and Act on Pharmacist Review
Penalty
Summary
Surveyors identified a failure to limit an as-needed psychotropic medication to 14 days for one resident. The resident had a BIMS score of 15/15, indicating intact cognition, and diagnoses including anxiety disorder, insomnia, chronic pain, muscle weakness, and a history of cerebrovascular accident or transient ischemic attack. Physician orders dated 12/8/25 showed the resident was receiving Ativan 0.5 mg every six hours as needed for anxiety without any documented stop date. A monthly medication review dated 12/29/25 documented that the pharmacist recommended limiting non-antipsychotic psychotropic medications to 14 days, but the physician declined this recommendation and deferred the issue to mental health, and the medical record contained no physician rationale for extended use or a stop date. The DON reported that staff were expected to follow up on monthly medication review orders placed in a binder at the nursing station, but there was no additional follow-up on the pharmacist’s recommendation by nursing or mental health services, despite facility policy stating that the physician/prescriber and DON should act upon recommendations in the monthly regimen reviews. This resulted in the continued use of an as-needed psychotropic medication without adherence to the 14-day limitation or documented justification for extended use, contrary to the facility’s medication regimen review policy.
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