Failure to Ensure PRN Psychotropic Medication Had Time-Limited Order and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident did not receive a PRN psychotropic medication beyond 14 days without documented medical necessity and an end date. One resident with an anxiety disorder, admitted on 10/20/25, had a physician’s order dated 12/05/25 for hydroxyzine 25 mg by mouth every 12 hours as needed for anxious behaviors. The order did not include an end date. Medication administration records for January 2026 show that the resident received hydroxyzine multiple times throughout the month, including on at least 16 separate occasions. During interviews, the Unit Manager stated that the resident had been on PRN hydroxyzine since admission and confirmed that the provider had not documented a rationale in the medical record for the long-term PRN use without an end date. The DON also confirmed that the PRN hydroxyzine was ordered indefinitely, that there was no provider-documented rationale in the resident’s record, and that his expectation is that the provider document a clinical rationale for any PRN hydroxyzine order with an end date greater than 14 days.
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