Expired, Undated Multidose Ativan Vial Administered to Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically related to a multidose vial of Ativan. A multidose vial of Ativan 20 mg/10 mL, used for treating anxiety and aggression, was opened on a documented date but was not labeled with the date opened or initials on the vial or its packaging. Despite the facility’s policy requiring multidose vials to be dated and discarded within 28 days of opening, the vial remained in use beyond this period. The Ativan narcotic count log showed the vial had been opened on a specific date, but the vial itself lacked any open date, and the expiration/beyond-use dating process required by policy was not followed. Resident #1, a male resident with dementia with behavioral disturbances, had physician orders for intramuscular Ativan 2 mg/mL in varying one-time doses for aggression, combativeness, and severe aggression. The February 2026 MAR documented that IM Ativan was administered to this resident on three separate dates by different nurses (LVN-C, RN-D, and LVN-E). Resident #2, a female resident with dementia with anxiety and generalized anxiety disorder, had a physician order for Ativan 2 mg/mL, 0.5 mL one time only for aggression and combativeness, and the February 2026 MAR showed Ativan 0.5 mL was administered on one date. These administrations corresponded with the same multidose vial of Ativan that had been opened more than 28 days earlier and was not properly dated on the vial. During observation, the Ativan vial was approximately one-third full, with no written open date or initials, and staff interviews confirmed that the vial had been opened on a date that made it expired under facility policy at the time it was administered to both residents. The ADON stated that multidose vials should be dated and initialed when opened and are only good for 28 days, and acknowledged that ADONs audit controlled medication logs only every couple of weeks. LVN-C, RN-D, and LVN-E each stated they did not check the vial for an open date or expiration prior to administration, despite acknowledging that nurses are supposed to verify that medications are not expired before giving them. The DON confirmed that the vial, opened on the documented date, should have been discarded 28 days later and that every nurse administering the medication should have checked when it was opened and whether it was expired. Facility policies on Medication Administration and Medication Labeling and Storage required dating of multidose vials when opened and discarding them within 28 days, which was not done in this case.
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