Failure to Remove and Destroy Discontinued Controlled Medication
Penalty
Summary
The facility failed to remove and destroy a discontinued controlled medication, lorazepam, as required by its own policy and federal/state regulations. After a physician's order for lorazepam injection was discontinued, the medication remained in the medication cart instead of being removed and secured for destruction by the Director of Nursing and another nurse. This lapse in procedure allowed the discontinued medication to remain accessible to staff. Subsequently, a resident with a history of epilepsy and recent seizure activity was administered the discontinued lorazepam during an episode of active seizure, despite there being no current physician order for its use. The medication was located in the narcotic drawer and given intramuscularly by a registered nurse after consultation with another nurse. The failure to remove and destroy the discontinued controlled substance directly led to its unauthorized administration to the resident.