Psychotropic Medication Administered Without Proper Physician Order
Penalty
Summary
A resident with diagnoses including autistic disorder, developmental disorder, and unspecified convulsions was admitted with severe cognitive impairment and required significant assistance with daily activities. The resident's care plan included administration of medications as ordered for a seizure disorder. A physician's order specified Lorazepam 1 mg by mouth every 24 hours as needed for seizures. However, on one occasion, Lorazepam was administered by an LPN for agitation and insomnia, not for seizures as indicated by the physician's order. The LPN consulted with the nursing supervisor, who authorized the administration despite the absence of a seizure and without obtaining a new physician order for agitation or insomnia. The LPN documented the administration of Lorazepam under the existing order for seizures, even though the medication was not given for that purpose. The nursing supervisor attempted to contact the physician for a new order but was unsuccessful and still permitted the medication to be given. Both the LPN and the nursing supervisor later acknowledged that Lorazepam should not have been administered for agitation or insomnia without a valid physician order. Facility policy requires that all medications be administered only with a valid physician's order and in accordance with facility protocols.