Failure to Follow Physician Orders for Lorazepam and Oxycodone Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for a resident with Hodgkin’s lymphoma and anxiety, contrary to its own medication administration policy. The facility policy dated February 12, 2026, required medications to be administered in accordance with prescriber orders and specified that bedtime medications be given up to one hour prior to the resident’s scheduled bedtime. Clinical record review showed that a physician’s order dated October 27, 2025, directed staff to administer lorazepam 0.5 mg, three tablets at bedtime. However, nursing progress notes and the Individual Patient Narcotic Dispensing Record documented that on December 11, 2025, an LPN administered only one lorazepam tablet at 5:30 p.m., rather than three tablets at the scheduled 8:00 p.m. bedtime. An additional physician’s order dated January 19, 2026, again directed staff to administer lorazepam 0.5 mg, three tablets at bedtime, but the narcotic dispensing record showed that on February 4, 2026, at 8:00 p.m., another LPN administered only one tablet instead of three. A separate order dated January 19, 2026, required oxycodone HCL (IR) 10 mg every four hours for pain. Review of the January 2026 Medication Administration Record revealed that the 8:00 p.m. oxycodone dose on January 29, 2026, was missed because no medication was available, as confirmed by a nursing progress note and the narcotic dispensing record, which showed the last dose on hand was given at 4:00 p.m. and the next dose not administered until midnight on January 30, 2026. In an interview, the Administrator stated there was no documented evidence that staff followed the physician orders as described.
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