Unauthorized Administration of Ativan Without Physician Order
Penalty
Summary
A medication error occurred when a nurse administered a liquid form of Ativan to a resident who did not have a physician's order for this medication or formulation. The resident, who had a history of atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness, agitation, and mood disorder, was observed to be anxious and agitated. The nurse gave the resident a liquid medication from a dropper, which was later confirmed through video review to be Ativan belonging to another resident. The medication administration record for the resident did not include any oral liquid medications, and there was no valid order for liquid Ativan at the time of administration. Staff interviews confirmed that the nurse gave the medication without a physician's order and used another resident's medication. The incident was reported by a CNA who witnessed the event and was corroborated by other staff, including the DON and RNs, who emphasized that medications should not be borrowed or administered without proper orders. The facility's policy requires strict adherence to the five rights of medication administration, including verifying the right resident, medication, dose, route, and time, and administering medications only from packaging labeled for the individual resident. This policy was not followed in this incident.