Psychoactive Medication Administered Without Documented Indication
Penalty
No penalty information released
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Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs when a psychoactive medication was administered without adequate indication for its use. A resident with multiple diagnoses, including depressive disorder, hypertension, and osteoporosis, had a physician's order for lorazepam to be given as needed for anxiety. The medication administration record showed that lorazepam was administered on two occasions, but there was no documentation of anxiety symptoms or behaviors at those times. The Director of Nursing confirmed that the medication was given without documentation of the required symptoms or behaviors, contrary to facility expectations.