Controlled Substance Administered Without Current Physician Order
Penalty
Summary
Nursing staff failed to follow professional standards for medication administration by administering a controlled substance, lorazepam, to a resident without a current physician's order on three separate occasions. The resident had a documented order for lorazepam 0.5 mg by mouth at bedtime for anxiety disorder, which was set to be discontinued after a specified date. Despite the discontinuation, the medication was administered on three dates following the order's expiration, as evidenced by the Medication Administration Record and the Controlled Substance Log. Interviews with staff confirmed that the medication card was not removed from the medication cart after discontinuation, and the required destruction of discontinued narcotics by two nurses did not occur. Staff interviews revealed a lack of adherence to facility policy and professional standards, as staff members acknowledged that medications should not be administered without a current order and that discontinued narcotics should be promptly removed and destroyed. The errors were not identified by the facility until over a month after the last administration, as documented in a misappropriation report. Facility policies and training documents reviewed clearly stated the necessity of following physician orders and proper procedures for handling discontinued controlled substances, which were not followed in this instance.