Failure to Administer Anti-Anxiety Medication as Ordered
Penalty
Summary
A resident with diagnoses of anxiety disorder and major depressive disorder was admitted to the facility with a physician's order for Xanax 0.5 mg by mouth four times daily at specific times. Review of the medication administration history over a three-week period revealed that 20 out of 82 scheduled doses were administered late, with some doses given up to several hours after the scheduled time. The medication administration record included comments indicating the late administration, and the facility's policy required medications to be administered within 60 minutes of the scheduled time unless otherwise specified by the prescriber. The resident reported receiving his anti-anxiety medication inconsistently and often late, which led to increased anxiety and distress. An LPN confirmed administering the medication late and was unaware of the required administration window. The nurse cited unfamiliarity with the unit and workload as contributing factors to the delays. The facility's policies and drug reference resources emphasized the importance of timely administration and even distribution of doses, but these were not consistently followed for this resident.