Inaccurate Documentation of PRN Lorazepam Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident with diagnoses including Parkinson’s disease and anxiety disorder. The resident was admitted on 11/3/23, and on 11/18/25 a physician ordered lorazepam 0.5 mg PO every 6 hours PRN for anxiety, nausea/vomiting, or agitation; this order was discontinued on 11/24/25. On 11/24/25, the same lorazepam PRN order was re-entered for 14 days and then discontinued on 12/8/25. On 12/8/25 at 3:52 PM, the physician documented in a progress note that the resident was on PRN Ativan, that positive benefit had been seen, and that the medication would be continued for one month. A new lorazepam PRN order for 30 days was entered on 12/8/25. Review of the resident’s November and December 2025 MARs and the facility’s narcotic sheet for lorazepam showed that no doses of PRN lorazepam were administered during those months. During an interview on 12/11/25, the ADON confirmed that no lorazepam doses had been given in November or December and stated that the resident was not taking the medication. Despite this, the 12/8/25 physician note documented that the resident had experienced positive benefit from PRN Ativan, with no medication administration records to corroborate that any doses had been given. This discrepancy demonstrated that the resident’s clinical record did not accurately and completely reflect the care and treatment provided.
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