F0760

E

Failure to Accurately Administer and Document Controlled Anxiolytic Medications

Hamden, Connecticut Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors related to anxiolytic medications, including incorrect dosing and omitted doses. For one resident with vascular dementia, anxiety disorder, and depressive episodes, a physician’s order directed administration of Ativan 0.25 mg (½ of a 0.5 mg tablet) three times daily for anxiety. However, documentation on the Medication Administration Record (MAR) and the Controlled Substance Disposition Record showed that from 12/10/25 through 12/23/25, nurses repeatedly administered 0.5 mg per dose instead of 0.25 mg, resulting in double the prescribed dose on at least seventeen occasions. The Controlled Substance Disposition Record also showed that after a later order change to 0.5 mg three times daily, the resident received only 0.25 mg at several subsequent administrations, which was half of the ordered dose. Charge nurses, including LPNs and an RN, later stated they had misread the physician’s orders and failed to compare the electronic MAR with the medication blister pack label before administration.

For a second resident with dementia, schizophrenia, anxiety, major depressive disorder, and epilepsy, a physician’s order directed lorazepam 0.5 mg by mouth every eight hours for anxiety and agitation. The January MAR indicated that lorazepam 0.5 mg was administered at scheduled times each day. However, review of the Controlled Substance Disposition Record did not show that the 5:00 AM dose on 1/3/26 was documented as administered, despite the MAR indicating it had been given. This discrepancy between the MAR and the controlled substance record demonstrated a failure to accurately document and verify administration of a controlled anxiolytic medication as ordered.

For a third resident with dementia with behavioral disturbances, paranoid personality disorder, generalized anxiety disorder, and major depressive disorder, a physician’s order directed Xanax 0.5 mg by mouth three times daily for anxiety and agitation. The January MAR showed that Xanax 0.5 mg was signed out as administered at the scheduled times. In contrast, the Controlled Substance Disposition Record did not reflect administration of the medication for six specific scheduled doses, even though all six were signed off on the MAR as given. The psychiatric APRN stated that licensed nurses are expected to fully read orders, follow the five rights of medication administration, and clarify any uncertainties, and the DON stated that nurses are expected to compare the physician’s order with the blister pack label and to document medications at the time of administration so that the MAR and Controlled Substance Disposition Record match. The facility’s own Medication Administration and Medication Errors policies defined medication errors to include omissions and wrong doses and required staff to follow written provider instructions and verify doses, which did not occur in these cases.

The psychiatric APRN also reported that no one contacted him to clarify or question the Ativan orders for the first resident until 12/24/25 and that he was not informed that any of the three residents had omitted doses of anxiolytic medications during the period in question. The APRN identified that all three residents had dementia and were at risk for increased anxiety, agitation, and impaired comfort when scheduled anxiolytic medications were omitted. The DON confirmed that licensed nurses did not follow expectations to fully read and verify orders and to ensure the five rights of medication administration, resulting in the wrong dose being given to one resident and undocumented or omitted doses for the other residents, and that the MARs should have matched the corresponding Controlled Substance Disposition Records but did not.

Overall, the survey findings show that for three residents receiving controlled anxiolytic medications, the facility failed to administer medications in accordance with provider orders and failed to maintain accurate, consistent documentation between the MAR and the Controlled Substance Disposition Records. These failures included administering double the ordered dose, administering half the ordered dose, and omitting or failing to document scheduled doses, contrary to facility policy and provider expectations.