Failure to Obtain Informed Consent for Lorazepam Prior to Administration
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for an antianxiety medication prior to administration for one resident. The resident was an elderly female with neurocognitive disorder with Lewy bodies and generalized anxiety disorder, admitted and later readmitted with a documented POA. A significant change MDS showed no BIMS score and documented physical, verbal, and other behavioral symptoms. Her care plan dated 1/12/2026 identified use of antianxiety medication related to anxiety disorder, with interventions including educating the resident and family about the risks, benefits, and side effects of the antianxiety drug and administering lorazepam while monitoring for specific side effects. A physician order dated 1/10/2026 directed lorazepam intensol oral concentrate 2 mg/mL, 0.5 mL by mouth every 2 hours as needed for anxiety and restlessness, entered by RN A. The MAR for January 2026 showed the resident received lorazepam multiple times on 1/13, 1/14, 1/19, 1/20, and 1/21. Review of the electronic medical record on 1/21/2026 revealed no evidence that the resident or her representative had consented to lorazepam. The resident’s POA reported being notified of the medication by hospice staff and did not recall facility staff explaining side effects, only knowing from her own understanding that lorazepam would cause drowsiness because it was for anxiety. Interviews with facility staff confirmed that the facility’s process required nurses to obtain informed consent for psychoactive medications prior to administration and that lorazepam required such consent. The DON stated she expected the charge nurse to obtain consent when entering the order and verified that no consent was present in the electronic record or in the basket where documents awaited upload. An LVN stated nurses were responsible for obtaining consents at the time orders were taken, that lorazepam required consent, and that she was unaware no consent existed for this resident. The medical records staff reported having no pending paperwork for the resident. RN A stated she received the lorazepam order from the hospice nurse, entered it into the record, told the hospice nurse to speak with the family because it was the middle of the night, and began the consent paperwork for day shift to obtain signatures, but did not know where that paperwork was if it was not in the record. Facility residents’ rights postings and facility policy required informed consent for psychoactive medications, including completion of a Verification of Informed Consent form upon initiation of new psychoactive medications, which was not documented for this resident’s lorazepam use.
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