Failure to Re-Evaluate PRN Antipsychotic Order Within Required 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to comply with requirements for PRN antipsychotic medications, resulting in a chemical restraint concern for one resident. The resident, an older adult with dementia, epilepsy, chronic pain, bipolar disorder, anxiety disorder, and a history of cerebral infarction, had a physician order for Seroquel 25 mg to be given by mouth three times a day as needed for agitation related to anxiety disorder, starting on 2/3/26. The February MAR showed that the PRN Seroquel was administered on three occasions (2/11/26, 2/14/26, and 2/22/26). Observations on 3/12/26 documented the resident in a wheelchair in the lobby with eyes closed, chin resting on the chest, and later with the tongue hanging out of the mouth, while a musician performed nearby. Record review and staff interviews revealed that the PRN Seroquel order remained active from 2/3/26 through at least 3/26/26 without documented re-evaluation by the physician or a mental health provider, despite facility policy limiting PRN psychotropic orders to 14 days and requiring an evaluation and documentation to renew PRN antipsychotic orders. A nurse stated that the physician re-evaluated PRN antipsychotics during quarterly gradual dose reductions and monthly order recapitulations, but could not identify any documentation of a specific re-evaluation or rationale for continuing this PRN Seroquel order. The medical director could not recall if he documented a re-evaluation and appeared unaware that documentation every 14 days was required to continue a PRN antipsychotic. The facility’s pharmacist reported that, during a recent medication regimen review, she noted the PRN Seroquel order and recommended its discontinuation. This failure resulted in the resident having the potential to receive an antipsychotic dose beyond the 14-day limit without the required re-evaluation.
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