F0684

D

Improper Alteration and Administration of PRN Lorazepam at End of Life

Gaylord, Michigan Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer a medication in the prescribed form for one resident receiving end-of-life care. The resident was admitted with diagnoses including malignant neoplasm of the lung, vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention. Documentation in the EMR showed that nursing staff noted the resident was not drinking or eating and was on hospice, and later documented that the resident could no longer swallow. Despite these entries, the Medication Administration Record showed that lorazepam oral tablets continued to be administered multiple times after it was documented that the resident could no longer eat, drink, or swallow.

During interviews, the complainant reported that near the end of the resident’s life, he was unable to swallow and that a nurse attempted to give a tablet with water, which caused the resident to choke. The complainant further stated that after this, staff dissolved the resident’s pills in other medication liquids to form a solution. The nurse who provided care confirmed that she dissolved lorazepam tablets into atropine solution to administer the medication and stated she did not believe a physician’s order was needed to change the form of the medication, indicating this was a common practice for end-of-life residents. The facility’s pharmacy consultant stated it was not standard practice to dissolve a tablet into another medication’s solution and noted that lorazepam is available in a liquid formulation. The DON initially stated that standing orders allowed medications to be crushed and dissolved into another medication unless contraindicated, but later the DON and NHA acknowledged the facility did not have a standing orders policy.