PRN Diphenhydramine Order Lacked Indication for Use
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when a resident had a PRN diphenhydramine order without an associated diagnosis or documented reason for use. The resident’s EMR showed diagnoses of insomnia and anxiety, an Annual MDS with a BIMS score of 15 indicating intact cognition, no skin issues, and independence with ADLs. The Psychotropic Drug Use CAA noted the resident was prescribed psychotropic medications for anxiety and would be closely monitored. However, the care plan dated 03/16/26 did not include diphenhydramine, and a physician order dated 11/12/25 directed administration of diphenhydramine 50 mg by mouth three times a day as needed, without specifying an indication. Review of the EMR from 11/12/25 through 03/17/26 showed no documentation of this PRN diphenhydramine order in progress notes, provider notes, dermatology notes, pharmacy notes, or psychiatric notes. During observations, the resident was seen independently ambulating, participating in activities, and reporting that she did not know all of her medications but would ask the nurse if she needed something, stating she had many options to choose from. The consultant pharmacist confirmed on 03/17/26 that the PRN diphenhydramine order lacked a reason or diagnosis and acknowledged missing this issue during the last medication review. A CMA, a licensed nurse, and an administrative nurse each stated that all medications, including PRNs, were required to have a diagnosis or reason for administration, and the administrative nurse acknowledged that the diphenhydramine order should have included a reason since its initiation on 11/12/25. The facility did not provide a policy on PRN medication orders.
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