Failure to Administer Correct Medication Formulation and Document PRN Administration
Penalty
Summary
Licensed staff failed to administer the correct formulation of lorazepam as ordered by the physician for a resident with Alzheimer's disease, dementia, and anxiety who was receiving hospice care. The physician initially ordered lorazepam tablets, which was later changed to a liquid concentrate form as recommended by hospice. Despite the order change, an LPN continued to administer lorazepam tablets on three occasions after the tablet order had been discontinued and the liquid concentrate had been prescribed. The LPN did not check the Medication Administration Record (MAR) prior to administration and was unaware of the change in formulation at the time. The MAR and nursing notes did not reflect administration of the tablets on those dates, and the LPN could not recall if documentation was attempted after administration. The facility's policy required staff to document as-needed medication administration, including the correct dosage form, and to follow the six rights of medication administration. The controlled substance disposition record confirmed that lorazepam tablets were removed for administration after the order had been changed to the liquid form. The error was discovered after another nurse informed the LPN of the formulary change. Interviews with facility staff confirmed that the correct medication formulation was not used as ordered, and the required documentation was not completed in accordance with facility policy.