Failure to Reconcile and Implement CIWA-Ar Protocol on Admission
Penalty
Summary
The facility failed to ensure that all admission orders were reported and reconciled with the physician for a resident admitted with a primary diagnosis of alcohol dependence with withdrawal. Upon review, it was found that the hospital discharge medication list included a CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) protocol for administering lorazepam based on withdrawal assessment scores. This protocol specified dosing and reassessment intervals, as well as instructions to notify the provider if certain thresholds were met. However, the as-needed CIWA protocol was not reconciled or implemented upon admission, unlike the other medications listed on the discharge summary. Interviews with the Director of Nursing (DON) and the assigned physician revealed that neither was aware of the CIWA protocol included in the hospital discharge documentation. The physician confirmed that they had not been informed of the protocol, and the DON acknowledged being unaware of its presence on the discharge medication list. There was no documentation or evidence that the protocol was reviewed or acted upon at the time of admission.