Failure to Administer and Document Scheduled Medication as Ordered
Penalty
Summary
Staff failed to provide medication as ordered for a resident with an anxiety disorder who had a physician's order for Lorazepam 0.5 mg three times daily. Medical record review showed that the medication was documented as administered every day in April, but the controlled drug administration record indicated that the last tablet from a 30-tablet supply was removed at 2:00 PM on 4/28, with no tablets left for the 8:00 PM dose that same day. A new supply was not received until the following morning, and there was no documentation that the interim supply was accessed for the missed dose. Despite the lack of available medication, staff documented that the 8:00 PM dose on 4/28 was administered as ordered. Review of pharmacy and automated dispensing records did not show that the interim supply was accessed for this dose, and the pharmacy was unable to provide documentation to account for the administration. The deficiency was identified through interviews and record reviews, which confirmed that the medication was not re-ordered in a timely manner and that staff failed to obtain it from the interim supply, yet still documented its administration.