Inappropriate Use of Anti-Anxiety Medication Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering an anti-anxiety medication, lorazepam (Ativan), without an appropriate clinical indication. The resident was admitted with diagnoses including Alzheimer's disease, vascular dementia, and major depressive disorder. The physician's order for lorazepam was documented as being related to Alzheimer's disease, which is not an appropriate indication for this medication. Staff interviews revealed that the resident did not exhibit behaviors consistent with anxiety, and staff acknowledged that Ativan is not typically prescribed for Alzheimer's disease. The order for lorazepam was carried over from the resident's admission documentation without proper review or correction of the diagnosis. Facility policy requires that psychotropic medications, including anti-anxiety drugs, be prescribed only when clinically indicated for specific, documented conditions. The policy also mandates comprehensive evaluation of residents before initiating such medications. Despite these requirements, the resident received lorazepam based on an inappropriate diagnosis, and staff failed to identify and correct the error during routine medication reconciliation and order review processes.