Incorrect Lorazepam Dose Administered Due to Failure to Verify MAR
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from significant medication errors when anti-anxiety medication was administered incorrectly. The resident had diagnoses of schizophrenia and anxiety, with MDS assessments showing initially intact cognition followed by moderately impaired cognition, and was identified as being at risk for side effects related to psychotropic medications. The resident’s care plan directed staff to monitor for adverse side effects from psychotropic drugs. Physician orders in the EMR specified lorazepam 1 mg PO at bedtime and lorazepam 0.5 mg PO twice daily for anxiety. On a morning medication pass, the Medication Administration Record documented that the resident received 1 mg of lorazepam at 08:00 instead of the ordered 0.5 mg morning dose. The facility’s investigation determined that the Certified Medication Aide administered the nighttime 1 mg dose in place of the ordered 0.5 mg morning dose and did not discover the error until another staff member prepared the afternoon lorazepam dose several hours later. The CMA later confirmed she had given the wrong dose and stated she had not checked the MAR and the medication card twice before administering the medication. The facility’s psychotropic drug policy required medications to be given according to the physician’s orders, which did not occur in this instance.
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