Failure to Administer and Document Medication per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety disorder and depression was not provided care in accordance with professional standards. The resident had a physician's order for Lorazepam 0.5 mg daily for anxiety, which was discontinued on May 3, 2025. Despite the discontinuation, Employee 1 continued to sign out and administer the medication for six days after the order had ended, from May 4 to May 9, 2025. During this period, there was no active order for daily Lorazepam, and the administration was not documented under the resident's as-needed (PRN) order for Lorazepam. The medication administration record (MAR) for the resident did not reflect any PRN doses given during the time the daily order was inactive, even though the controlled drug record showed continued administration. This discrepancy was identified after the Director of Nursing was notified and an investigation was conducted. The failure to ensure that medication was administered and documented according to current physician orders and professional standards resulted in the cited deficiency.