Unauthorized Administration of Controlled Substance and Misappropriation of Medication
Penalty
Summary
A nurse administered a liquid medication, specifically Ativan (Lorazepam Oral Concentrate), to a resident who did not have a physician's order for this form of the medication. The resident's medication administration record (eMAR) showed only an order for Ativan tablets, not the liquid form, at the time of administration. The incident was observed by a CNA, who reported that the nurse stated she was giving an 'extra dose' and asked the CNA not to witness the act. Video evidence confirmed the nurse gave the resident a liquid medication with a distinctive white stopper, which matched another resident's prescribed Ativan. The nurse did not document the administration of this medication to the resident and instead recorded a dose for the resident who was actually prescribed the liquid Ativan. The facility's investigation determined that the nurse gave a controlled substance to a resident without a valid order and used medication prescribed for another resident. This was classified as a medication error, unauthorized administration of a controlled substance, and a violation of resident rights and safety standards. Staff interviews confirmed that such actions are outside the scope of nursing practice and violate facility policy, which prohibits the use of a resident's possessions, including medications, without proper authorization.