Failure to Limit and Review PRN Antipsychotic Medication Order
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to limit a PRN antipsychotic medication order to 14 days and to ensure practitioner evaluation for renewal. The facility’s policy on psychotropic medication, dated 10/12/2025, stated that PRN psychotropic orders must be used only for a diagnosed specific condition documented in the clinical record and for a limited duration of 14 days, and that if the practitioner believed it appropriate to extend the PRN order beyond 14 days, the duration must be specified. Record review showed that this policy applied to psychotropic medications, including antipsychotics. Record review for one resident revealed an admission date of 1/29/26 and diagnoses including dementia in other diseases classified elsewhere with behavioral disturbance, non-ST-elevation myocardial infarction, Parkinson’s disease with dyskinesia and fluctuations, and unspecified depression. The resident had a PRN order for Zyprexa 5 mg by mouth every 6 hours as needed for agitation/outbursts related to dementia, with an order date of 2/6/26. The order did not include an end date. During an interview, the DON and Interim DON confirmed that there was no end date on this PRN antipsychotic order and that there were no physician notes documenting a review of the PRN antipsychotic medication, contrary to the facility’s policy and regulatory requirements.
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