Failure to Ensure Availability of Prescribed PRN Anti-Anxiety Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed PRN anti-anxiety medication, alprazolam, was available and could be administered as ordered for one resident. The resident was admitted with diagnoses including a left artificial knee joint, anxiety disorder, and depression, and was documented on the H&P as having capacity to understand and make medical decisions, with the MDS showing no cognitive impairment or change in mental status. Physician orders dated 12/17/2025 prescribed alprazolam 0.5 mg once daily PRN for anxiety manifested by episodes of inability to relax, with instructions for nurses to monitor episodes every shift, document non-drug interventions, and document effectiveness. Review of the MAR showed no alprazolam administration from 12/17/2025 through 12/29/2025, and progress notes did not show that licensed nurses contacted the pharmacy to obtain the medication during that period. The resident reported requesting alprazolam several times between 12/17/2025 and 12/27/2025 and being told by an LVN that the medication was not available; staff offered non-pharmacological interventions that were not always effective, and the resident stated that not having the medication worsened his anxiety and caused frustration and discouragement. The pharmacist stated she received the alprazolam order on 12/19/2025 but could not dispense it because it lacked the required handwritten physician signature, and that facility staff did not contact the pharmacy about the order from 12/20/2025 through 12/28/2025; a signed order was not provided until 12/29/2025, when the medication was sent. The pharmacist and RN confirmed alprazolam was not stocked in the e-kit, so no emergency supply was available. The DON and RN acknowledged that the resident did not have access to alprazolam as ordered from 12/17/2025 through 12/28/2025, that PRN medications should be in stock within two days of admission, and that the facility’s “Administering Medications” policy requiring safe and timely administration as prescribed could not be followed during that time.
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