Failure to Document Behaviors and Administer Anti-Anxiety Medication Within Prescribed Time Frame
Penalty
Summary
A deficiency occurred when a resident with diagnoses including restlessness and agitation exhibited physically aggressive behaviors, such as attempting to throw a chair and flipping tables. Following these incidents, a nurse practitioner ordered Lorazepam 0.5 mg IM every 8 hours as needed for anxiety. The resident received the first dose at 8:15 p.m., with the next eligible dose at 3:15 a.m. However, the second dose was administered at 2:30 a.m., which was outside the prescribed time frame. Additionally, there was no documentation in the clinical record of the resident's behaviors to justify the administration of the second dose of Lorazepam. Facility policy required that psychoactive medications, including anti-anxiety drugs, be administered in accordance with physician orders and within 60 minutes of the scheduled time, with nursing staff responsible for monitoring and documenting target behaviors. Interviews confirmed that behaviors should be documented in the nurses' notes and that medications can be administered within an hour before or after the scheduled time. The lack of documentation for the resident's behaviors prior to the second dose, as well as the administration of the medication outside the appropriate time frame, constituted a significant medication error.