Failure to Limit and Reassess PRN Psychotropic Medication Use Beyond 14 Days
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services did not continue to receive a PRN psychotropic medication beyond 14 days without appropriate evaluation and documentation. The resident was admitted on 11/04/24 and had an order dated 12/23/25 for lorazepam 0.5 mg, with instructions to administer 0.25 mg every four hours PRN for agitation and restlessness. Review of the Medication Administration Record showed multiple administrations of lorazepam from late December through January, including doses on 12/24/25, 12/26/25, 12/29/25, and 12/30/25, and frequent administrations throughout January. There was no documented reassessment by the prescriber or documentation of clinical indications to justify extending the PRN psychotropic medication order beyond 14 days. During interviews, the Consultant Pharmacist stated that any PRN psychotropic medication order must include a 14-day stop date, after which the medical provider must reassess the need for continued use and document justification in the clinical record, and that this requirement also applies to residents on hospice. In contrast, the DON stated that the PRN lorazepam order did not require a 14-day end date because the resident was receiving hospice services. Review of the facility’s “Use of Psychotropic Medications” policy dated 02/18/25 indicated that PRN orders for psychotropic medications, excluding antipsychotics, are limited to 14 days unless the prescriber documents the rationale and specific duration for extending the order, which was not done in this case.
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