Failure to Administer PRN Medication at Prescribed Time and Incomplete Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to administer lorazepam to a resident according to the physician's prescribed time frame. The resident, who had diagnoses including type 2 diabetes mellitus, unspecified dementia with anxiety, depression, and post-traumatic stress disorder, was admitted for respite care. The medication order specified lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety. However, the medication was administered earlier than ordered, as the nurse did not verify the timing of the previous dose. The error was identified when the nurse, after administering the medication, realized during documentation that the dose had been given too soon. The nurse acknowledged not checking the five rights of medication administration, specifically the right time, due to being distracted by other duties, such as redirecting the resident's behavior. The nurse also failed to document the administration on the Medication Administration Record (MAR) as required by facility policy, although it was recorded on the Controlled Substance Accountability Sheet. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the medication was given too early and that proper procedures, including checking the last administration time and documenting on the MAR, were not followed. Facility policy requires medications to be administered within 60 minutes of the scheduled time and for all administrations to be recorded on the MAR immediately after administration. The failure to follow these procedures resulted in the resident receiving lorazepam earlier than prescribed.