F0552

D

Failure to Obtain and Document Informed Consent for Lorazepam Use

Meridian, Idaho Survey Completed on 04-03-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to ensure a resident was informed in advance of care and treatment, including the risks and benefits, before initiating a new medication. One resident with multiple diagnoses, including palliative care encounter, congestive heart failure, and acute kidney disease, had physician orders for lorazepam oral concentrate 2 mg/mL, to be given 0.5 mL by mouth every 8 hours as needed for anxiety and every 8 hours as needed for terminal agitation for 180 days. Record review showed no documentation that the resident or the resident’s representative had been informed of the risks and benefits of lorazepam or had provided consent prior to lorazepam being added as an active order. In an interview, the clinical resource nurse confirmed that neither the resident nor the representative had signed a consent documenting understanding of the risks and benefits of the lorazepam treatment.

This failure to obtain and document informed consent for lorazepam use for this resident, whose record was reviewed for informed consent, was identified as a deficiency related to ensuring residents are fully informed and understand their health status, care, and treatments.