F0605

D

Failure to Apply 14-Day Stop Date to PRN Psychotropic Medication Order

Waynesville, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication, Clonazepam, had a required 14‑day stop date for a resident with an anxiety disorder. The resident was cognitively intact and had documented use of antianxiety medications. Her care plan identified the use of psychotropic medications with potential adverse effects and included an intervention to administer medications per physician orders. A physician order dated 2/19/26 for PRN Clonazepam, one tablet by mouth every 24 hours as needed for anxiety, was entered into the electronic medical record by a nurse without a stop date. Review of the MAR showed that this PRN Clonazepam order remained active beyond initiation and that the resident received at least one PRN dose on 2/19/26.

Interviews revealed uncertainty among staff and the Medical Director about how the PRN Clonazepam order was initiated and why it lacked a 14‑day stop date. The resident reported having both a scheduled bedtime dose and a PRN dose of Clonazepam, which she believed she could receive every 12 hours and stated she had this PRN order for a long time. The nurse who administered the PRN dose could not recall how the order was obtained. The Unit Manager stated she was not present when the order was started and did not remember checking it, but acknowledged that PRN psychotropic medications should only be ordered for 14 days. The Medical Director stated he did not see the resident on the date the order was started, did not know how the order was initiated, and confirmed that PRN psychotropic medications should have a 14‑day stop date. The DON and Administrator both indicated that new medication orders were typically reviewed in morning meetings, but this PRN Clonazepam order without a stop date was missed in that process.