Medication Administration Error: Injectable Lorazepam Given to Wrong Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia, mood disturbance, and non-Alzheimer's dementia, who had moderately impaired cognition, was administered an intramuscular injection of Lorazepam solution 1 MG that had been prescribed for another resident. The facility's policy on medication administration explicitly prohibits sharing medications between residents and requires that the right medication be given to the right resident, at the right time, by the right route, and in the right dose. The resident was only prescribed Lorazepam oral tablets, not the injectable form, and there was no documentation that the injectable Lorazepam had been dispensed by the pharmacy for this resident. During the incident, the DON stated that the resident was experiencing escalating behavior and was evaluated by a psychiatrist who ordered an immediate intramuscular injection of Lorazepam. The Nurse Educator retrieved the medication from another unit, did not verify the name on the medication bag, and assumed it was a stock medication. The Nurse Educator prepared the medication, which was then administered by the DON. It was later discovered that the Lorazepam solution used was not a house stock medication but had been prescribed for another resident. Both the Nurse Educator and DON confirmed that Lorazepam solution was not stocked as an emergency medication in the facility.