Failure to Ensure Timely Acquisition and Documentation of Prescribed Ativan
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition and administration of Ativan, a medication prescribed for anxiety. The resident, an elderly female with diagnoses including anxiety, heart disease, and kidney disease, was admitted with moderate cognitive impairment. Physician orders were in place for Ativan 0.25 mg every 12 hours as needed for agitation, and the care plan included monitoring the effectiveness of psychotropic medications. On the day of increased agitation, nursing staff obtained Ativan from the emergency kit, halved the tablet, and administered the dose, but did not document the administration on the medication administration record (MAR). Further review revealed that the order for Ativan was faxed to the pharmacy, but the required written prescription for the controlled substance was not received by the pharmacy, resulting in the medication not being delivered. The facility's medication binder did not contain the order or fax confirmation, and the process for reconciling and following up on medication orders was not completed as required. Interviews with staff confirmed that the necessary follow-up to ensure the medication was received did not occur, and the facility's procedures for ordering and documenting controlled substances were not followed.