Failure to Account for and Provide Ordered Lorazepam Doses
Penalty
Summary
The facility failed to provide accurate accountability and timely availability of a controlled medication, lorazepam 0.5 mg, for one resident with an order for daily administration for anxiety. During a narcotic count on one shift, RN A and the night shift nurse (RN B) were unable to locate the resident’s lorazepam bubble pack in the Station 2 medication cart. RN A reported that three medication carts and 48 resident rooms were searched, but the medication could not be found. RN A contacted the pharmacy for a replacement, and the pharmacy indicated the refill was too early and would require DON authorization. As a result, the resident’s ordered lorazepam doses were not available for administration on two consecutive mornings. Review of the physician’s order dated 9/24/25 showed the resident was to receive lorazepam 0.5 mg by mouth once daily for anxiety, evidenced by repetitive questions and verbalizations. The MAR documented that lorazepam was not administered on two specified dates, and the DON confirmed that the medication had been missing since RN B’s night shift and that the resident missed those two morning doses. During an observation and interview, the DON also confirmed there was no lorazepam available in any of the five E-kits. The facility’s policy on controlled substances required compliance with all laws and regulations related to handling, storage, disposal, and documentation of controlled medications, but the missing lorazepam and resulting missed doses demonstrated a failure to meet this requirement for this resident.
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