Failure to Administer Ativan as Ordered and Notify Physician of Ineffectiveness
Penalty
Summary
The facility failed to ensure that Ativan (lorazepam) was administered to one resident according to physician orders and professional standards. Specifically, the resident received two doses of Ativan 0.5 mg tablets by mouth only two hours and eight minutes apart, despite the order specifying administration every six hours as needed. There was no documentation that the physician was notified of this medication error. Additionally, the resident was given an intramuscular (IM) dose of Ativan without first attempting the oral (po) dose as required by the physician's order, and again, there was no evidence that the physician was informed of this deviation from the prescribed protocol. Further review revealed that when the resident received an oral dose of Ativan and it was documented as having "No Effect" after one hour, there was no record that the physician was notified of the medication's lack of effectiveness. The Director of Nursing confirmed during interviews and record reviews that these actions did not align with the physician's orders or expected nursing practice, and that appropriate notifications to the physician were not made in these instances.