PRN Psychotropic Medication Order Lacked Required Stop Date
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication order included a required stop date for one resident receiving an antianxiety medication. Record review showed that the resident’s physician order sheet, dated 11/5/25, contained an order for Ativan 0.25 ml sublingual every 2 hours as needed for anxiety, with no stop date indicated. During interview, the Nurse Manager stated he was responsible for ensuring psychotropic medications had appropriate diagnoses and stop dates and acknowledged he was not aware that this antianxiety order lacked a stop date, noting that the order was carried out by hospice staff and should have been clarified. He further stated he did not know why the order was entered into the electronic chart without a stop date and later produced a separate document for the antianxiety order that was not reflected in the resident’s medical record, despite his assertion that all ordered medications, including psychotropics with stop dates, should appear there. The facility’s psychotropic medication policy, dated 8/25, documents that psychotropic medications are to be used, evaluated, and monitored in accordance with state and federal guidelines.
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