Misappropriation of Controlled Medication Due to Improper Administration
Penalty
Summary
The facility failed to prevent the misappropriation of a controlled medication when Ativan, prescribed for one resident, was administered to another resident. The affected resident had a history of neurocognitive disorder with Lewy Bodies, anxiety, and depression, and was cognitively intact at the time of the incident. Physician orders specified that Ativan was to be administered intramuscularly as needed for seizures, and the medication was discontinued after a set period. Review of the controlled drug records showed that a dose of Ativan was signed out for administration, but it was not given to the intended resident. An interview with the Director of Nursing (DON) confirmed that the Ativan intended for one resident was instead administered to another resident, and there was no documentation in either resident's medical record regarding this transfer. The DON acknowledged signing out the medication but stated that an LPN actually administered it. The facility's medication administration policy required verification of the resident's name and medication details before administration, and specified that if a medication was unavailable, the contingency box should be used. However, the LPN failed to follow this policy and took the medication from another resident's supply instead.