Failure to Prevent Significant Medication Errors in Ativan Administration
Penalty
Summary
A deficiency was identified when a resident with a history of anxiety and receiving regular dialysis treatments did not consistently receive Ativan (Lorazepam) as ordered. Medical record review showed that the resident was prescribed Ativan 0.5 mg at bedtime and a combination of 1.0 mg and 0.5 mg prior to dialysis sessions. However, documentation on drug control sheets failed to confirm that the evening dose of Ativan was removed from the supply on seven specific dates, despite staff recording its administration on the medication administration record (MAR). Additionally, on three occasions, a 1.0 mg dose was removed and presumably administered instead of the ordered 0.5 mg dose, indicating the resident may have received double the intended dose on those evenings. Further review revealed that duplicate orders for Ativan 0.5 mg to be given with 1.0 mg on dialysis days resulted in staff documenting administration of two 0.5 mg tablets and one 1.0 mg tablet on certain mornings, leading to a total of 2.0 mg being given instead of the ordered 1.5 mg. The discrepancies between the MAR and the drug control sheets, as well as the lack of documentation for medication removal, indicate failures in both medication administration and controlled substance documentation for this resident.