F0757

D

Unclear PRN Lorazepam Orders Lead to Nurse-Selected Dosing

Modesto, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs by maintaining clear, physician-directed parameters for PRN psychotropic medication. A male resident with a history of hypertension, hyperlipemia, prostate cancer, depression, dementia, and obstructive sleep apnea had been admitted after hospitalization for altered mental status and a recurrent right subdural hematoma. Review of his electronic medical record showed that, as of a specific date, he had two active PRN orders for lorazepam, both written for anxiety manifested by aggressive behavior, but with different dosages and frequencies: 0.5 mg every 12 hours PRN and 1 mg every 24 hours PRN. Both orders carried the same indication and lacked distinct administration criteria to differentiate when each dose should be used.

During interviews and record reviews with the DON, Medical Records Director, and nursing staff, it was confirmed that both lorazepam orders were active simultaneously and that the orders did not specify clear parameters for choosing between the 0.5 mg and 1 mg doses. The DON acknowledged that the orders were confusing and that the administration instructions did not differentiate the two doses. LVN 1 and LVN 2 both stated that nurses were using their own nursing judgment to decide whether to administer 0.5 mg every 12 hours or 1 mg every 24 hours for aggressive behavior, based on their experience, comfort level with the resident, and assessment of the resident’s agitation. LVN 2 confirmed that she had administered the 1 mg dose twice and that her rationale for choosing the higher dose was her judgment that the resident was very agitated and yelling in the hallway, and that the family wanted the resident comfortable.

The consultant pharmacist, upon review of the medication orders and MAR, stated that at the time of the monthly review the resident had only one lorazepam order and that the 1 mg order was added later. The pharmacist noted that, with both orders active, the resident could potentially receive a total of 2 mg of lorazepam in 24 hours if both orders were carried out, and that the physician should have discontinued one order or clarified the administration instructions. The pharmacist and DON both indicated that medication orders should not rely on nurses’ judgment alone to determine dose selection and that PRN orders should have clear, defined parameters, including the expectation to use the lowest safe dosage for psychotropic medications. Facility policies on Medication Therapy and Administering Medications required that each resident’s medication regimen include only necessary medications, that orders be supported by appropriate care processes, and that there be a clear indication, appropriate dosage, and appropriate frequency and duration, which were not met in this case due to the duplicative and non-specific PRN lorazepam orders.