Unauthorized Medication Administration and Failure to Follow Weight Management Policy
Penalty
Summary
A nurse administered a benzodiazepine (Ativan) to a resident without a physician's order, using medication that belonged to another resident. The nurse attempted to control the resident's behaviors by disguising the medication in a milkshake. Shortly after receiving the unauthorized medication, the resident fell while moving to allow another resident to pass, resulting in a sprained hip and requiring evaluation at a local emergency room. The incident was later substantiated through review of video footage and staff interviews, confirming the medication error and the subsequent fall. Additionally, the facility failed to follow its own weight management policy for another resident. The policy required that if a resident experienced a weight difference of 5 pounds, a re-weigh should occur the following day to verify the change. However, after a resident lost five pounds between two weigh-ins, the required next-day re-weigh was not performed, as confirmed by record review and staff interview.