F0605

D

Failure to Monitor PRN Psychotropics and Enforce 14-Day Limits

Fort Collins, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately monitor and manage the use of psychotropic medications, specifically PRN lorazepam and Seroquel, for one resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. The resident had Lewy body neurocognitive disorder, parkinsonism, and anxiety, and the MDS documented severe cognitive impairment with no recorded physical or verbal behaviors toward others during the assessment period, although the resident was receiving antipsychotic and antianxiety medications. The facility’s psychotropic care plan for this resident, initiated in November, included interventions such as administering medications as ordered and monitoring for side effects and efficacy each shift, as well as consulting with the pharmacist and physician for possible dose reductions at least quarterly.

Record review showed multiple PRN lorazepam and Seroquel orders that exceeded the 14‑day limit for PRN psychotropic medications without documented physician reevaluation or rationale for continuation beyond that limit. One PRN lorazepam order in October was continued for 25 days, 11 days beyond the 14‑day limit, and a PRN Seroquel order was continued for 22 days, 8 days beyond the limit. In January, another PRN lorazepam order was continued for 23 days, 9 days beyond the 14‑day limit. The MAR documented frequent administration of PRN lorazepam over several months, including doses given during periods when the PRN orders had been continued past 14 days without documentation of reevaluation. The resident also received a PRN dose of Seroquel after the 14‑day limit had passed. There was no documentation in progress notes or hospice notes that the physician had reevaluated the PRN lorazepam to justify its use beyond 14 days.

The facility also failed to ensure behavior and side‑effect monitoring for the resident’s lorazepam and Seroquel. The EMR did not show any standing orders for behavior monitoring until an order was entered during the survey, and there was no evidence of consistent behavior monitoring by nursing staff prior to that time. There were no physician orders for side‑effect monitoring for either lorazepam or Seroquel, and no documentation of consistent side‑effect monitoring. Pharmacy medication regimen reviews had previously recommended that behavior tracking be in place for all antipsychotic and anxiolytic medications, that all PRN psychotropics have a 14‑day stop date, and that PRN antipsychotics not be continued beyond 14 days without a new order and justification. These recommendations were not implemented until months later, during the survey period. Staff interviews indicated that nurses and the DON understood that psychotropic medications required behavior and side‑effect monitoring and that PRN psychotropic orders should not exceed 14 days, but the DON acknowledged that behavior and side‑effect monitoring orders were not in place for this resident’s psychotropic medications and that new medication orders were not being reviewed daily.