Administration of Controlled Substance Without Physician Order During Seizure Event
Penalty
Summary
Nursing staff failed to ensure that care was provided in accordance with professional standards of practice when lorazepam, a controlled substance, was administered to a resident experiencing seizures without a current physician's order. The facility's policies required that medications be administered only as prescribed and that orders be confirmed prior to administration. The resident, who had a history of epilepsy with status epilepticus, had a previous order for lorazepam for agitation, but this order was discontinued and not active at the time of the incident. On the day of the incident, the resident experienced two episodes of seizures. During the first episode, the nurse attempted to contact the physician for an order to administer lorazepam but was unable to reach them and was advised by the on-call nurse not to administer the medication without explicit approval. During the second, prolonged seizure episode, another nurse insisted that lorazepam be administered due to the emergency nature of the situation, and the medication was given intramuscularly without a current order while the resident was still seizing. Emergency medical services were called, and the resident was subsequently transported to the hospital. Interviews with facility staff, including the DON, PA, and Medical Director, confirmed that the administration of lorazepam occurred without a valid physician's order and that this action was outside the nursing scope of practice. The incident was substantiated through internal investigation and staff interviews, which verified that the medication was administered from discontinued stock and without proper authorization.