F0605

D

Failure to Limit PRN Psychotropic Medications to Required 14-Day Duration

Meridian, Mississippi Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The facility failed to ensure PRN psychotropic medications were limited to a 14-day duration or renewed with documented physician rationale for one resident. Facility policy dated 4/28/25 required that PRN psychotropic medications, excluding antipsychotics, be limited to no more than 14 days, and that PRN antipsychotics be limited to 14 days with no exceptions. The resident, admitted on 8/27/2024, had dementia and a BIMS score of 00 on a quarterly MDS with an ARD of 2/16/2026, indicating severely impaired cognition. Record review showed active physician orders as of 3/1/26 for Diazepam 2 mg PO every 12 hours PRN for muscle spasms (ordered 12/30/2025) and Lorazepam 1 mg equivalent (0.5 mL of 2 mg/mL oral concentrate) PO every 6 hours PRN for agitation (ordered 12/29/2025), with no stop dates indicated.

A pharmaceutical consultant report dated 1/26/26 identified the resident as prescribed psychoactive medications and specifically noted that PRN psychotropic orders are limited to a 14-day supply. The DON confirmed that Lorazepam and Diazepam are psychotropic medications and that PRN psychotropics must be limited to 14 days unless the physician documents a clinical rationale and specifies a longer duration, acknowledging that the staff member who entered the orders did not include end dates and that this was inconsistent with regulatory requirements and facility expectations. The Administrator also confirmed that the PRN psychotropic orders lacked the required 14-day stop dates. The pharmacy consultant further confirmed that the PRN Lorazepam and Diazepam orders should have been limited to 14 days or discontinued absent a new physician order or documented justification, and stated that the facility is responsible for ensuring PRN psychotropic medications are monitored and discontinued or renewed within the required timeframe.