Failure to Maintain Controlled Substance Records and Accurate Lorazepam Dosing
Penalty
Summary
The deficiency involves the facility’s failure to maintain required controlled substance records for lorazepam administered to one resident and to ensure accurate transcription and dosing of that medication. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, PTSD, and a history of substance overuse. The care plan directed staff to administer medications as ordered, remain non-judgmental, monitor for behavioral changes, increase supervision as needed, and conduct medication review with pharmacy per facility protocol. Hospice admission orders for lorazepam concentrate 2 mg/mL directed 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the order was entered into the EHR, it was transcribed as lorazepam oral concentrate 2 mg/mL, 0.5 mL by mouth every 2 hours as needed, and this order remained active until it was discontinued several days later. The March MAR showed multiple administrations of lorazepam under the incorrectly transcribed order by various staff on several dates and times. The facility was unable to locate a controlled substance log for the resident’s lorazepam solution, despite the expectation that a controlled substance log be initiated and completed with each administration. The MDS Coordinator reported she transcribed the lorazepam order while working as a floor nurse, was in a rush, did not have another nurse double-check the order, and administered 0.5 mL of lorazepam, later identified as an incorrect dosage. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, and that a controlled substance log should be used for lorazepam. The Administrator reported there were no written policies and procedures for medication administration and that the facility followed the general “6 rights” of medication administration.
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