Abrupt Discontinuation of Benzodiazepine Without Physician Notification
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and diagnoses including developmental intellectual disability, depression, and anxiety disorder had their prescribed Ativan (a benzodiazepine) 1mg three times daily stopped abruptly without physician notification or a tapering process. The resident's care plan required medications to be given as ordered and for staff to monitor and document side effects and effectiveness. Pharmacy records confirmed the medication was being filled and administered as ordered until it was discontinued. On the date of discontinuation, 32 Ativan pills were wasted with two nurse witnesses, and the medication order was removed from the Medication Administration Record (MAR) without contacting the physician or the resident's Power of Attorney. Following the abrupt cessation of Ativan, the resident was found unresponsive on the floor, with cool and clammy skin and high blood pressure, requiring emergency medical services and hospital transfer. The hospital diagnosed the resident with benzodiazepine withdrawal, delirium, and syncope. Interviews with facility staff and the medical director confirmed that the physician was not notified of the discontinuation, and the medical director stated that any controlled medication, especially at a high dose, should be tapered gradually to prevent withdrawal symptoms. The facility's medication administration policy required documentation of any medication changes and up-to-date MARs, which was not followed in this case.