F0755

E

Failure to Administer and Document Lorazepam per Physician Orders

Temple, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services, including accurate acquiring and administering of medications, for one resident who had physician orders for both scheduled and PRN lorazepam. The resident was an elderly male with vascular dementia, Alzheimer’s disease, type 2 diabetes, atrial fibrillation, chronic kidney disease, and a history of repeated falls, and had a BIMS score indicating severe cognitive impairment. His care plan included pain medication therapy with monitoring and documentation of side effects and effectiveness each shift. Physician orders in the EMR included a scheduled lorazepam 0.5 mg tablet to be given every morning and at bedtime for anxiety/agitation related to dementia, and a separate PRN order for lorazepam (Ativan) 1 mg every 4 hours as needed for anxiety.

Review of the December MAR showed that the scheduled 0.5 mg lorazepam doses were signed as given on multiple mornings and bedtimes, while the narcotic count sheet documented that 1 mg lorazepam tablets were signed out and administered at corresponding times. Multiple LVNs who worked those medication passes stated in interviews that they administered 1 mg lorazepam tablets instead of the ordered 0.5 mg dose, did not waste any portion of the 1 mg tablets, and did not follow the physician’s order for the 0.5 mg scheduled dose. One LVN stated the 0.5 mg tablet was not available, so the 1 mg tablet was given and documented under the 0.5 mg order in the MAR. Another LVN acknowledged signing the MAR for 0.5 mg while actually giving 1 mg and not correcting the documentation.

The DON initially characterized the issue as a documentation error and stated that nurses were halving 1 mg tablets and wasting the remainder, but this was contradicted by the LVNs, who denied wasting and confirmed giving full 1 mg doses. The pharmacy nurse reported that nurses told her they were using the 1 mg PRN tablets and administering half, but also acknowledged that they had not documented any wasting on the narcotic count sheet and she did not verify whether a witness was present for any waste. The medical director stated she was aware of narcotic medication errors and nurses wasting medications and expressed concern that the resident may have received more than the scheduled lorazepam dose. The ADM and DON both stated expectations that staff follow physician orders, administer medications as ordered, and document administration and any waste correctly, and noted that incorrect MAR documentation and narcotic records create uncertainty about whether the resident actually received medications as ordered. Facility policies required medications to be administered as prescribed, documented accurately in the MAR, and controlled substances to be reconciled with appropriate records of dispensing, waste, and inventory.

This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.