Administration of Unordered Anxiety Medication Dose
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of generalized anxiety received additional doses of Lorazepam without a corresponding physician's order. The resident's care plan indicated a risk for anxiousness and directed that medications be administered as ordered by the physician. However, the clinical record showed that Lorazepam, prescribed for administration at bedtime, was also given at 8:00 a.m. on multiple dates. There was no documentation of a physician's order authorizing these additional morning doses. Further review of the controlled drug records for May and June revealed that the medication was administered twice daily on several occasions, despite the absence of an order for the morning dose. The medication administration records did not document these extra doses. During interviews, staff confirmed that medications should not be administered without a physician's order, and facility policy required medications to be given only as prescribed.