Lack of Physician Rationale for Extended PRN Lorazepam Use
Penalty
Summary
The facility failed to document the rationale for the continued use of a PRN anti-anxiety psychotropic medication for one resident. Clinical record review showed that Resident 83 had dementia with behavioral disturbance and anxiety, and the MDS assessment indicated the resident had been administered an anti-anxiety medication. The care plan identified use of an anti-anxiety medication related to an anxiety disorder, with an intervention for staff to administer medications as ordered. On June 24, 2025, a physician ordered Lorazepam gel to be given every eight hours as needed for anxiety. Medication Administration Records showed that this PRN Lorazepam gel was administered five times in July 2025, five times in August 2025, and nine times in September 2025. There was no documentation in the clinical record from the physician providing a rationale to extend the PRN Lorazepam gel order beyond 14 days from the original order date. In an interview on October 10, 2025, the Director of Nursing confirmed that there was no stop date or rationale in the orders to extend the PRN Lorazepam medication, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) for nursing services.
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