Borrowing Controlled Medication Between Residents in Violation of Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were delivered according to professional standards of quality when a controlled medication prescribed for one resident was taken and administered to another resident. On the night in question, a physician issued a new STAT order for Lorazepam 0.5 mg by mouth for a resident experiencing anxiety. The DON informed the physician that the ordered medication was not available in the facility for that resident, the distributing pharmacy was closed, and the resident’s family did not want the resident sent to the ER for evaluation. Despite this, the physician verbally instructed the DON that nurses were to borrow Lorazepam from another resident who had 0.5 mg Lorazepam tablets available in the facility. Following this instruction, the DON relayed to nursing staff that they were to use the other resident’s Lorazepam for the anxious resident when other comfort or distraction measures failed. An LPN subsequently removed a 0.5 mg Lorazepam tablet from the first resident’s medication card and administered it orally to the second resident. The medication was effective in relieving the second resident’s anxiety. The first resident’s controlled medication, which was ordered specifically for that resident, was therefore used for another resident, and the facility later arranged for the tablet to be replaced. Interviews with the administrator, DON, and consultant pharmacist confirmed that borrowing medications from one resident to administer to another is not acceptable clinical practice and does not meet professional standards of care. The administrator and DON acknowledged that the facility did not follow its own policies and procedures for medication ordering or resident treatment in this situation. Policy review showed that controlled substances are subject to special ordering, receipt, and recordkeeping requirements, and that when medications are not available, nursing staff are to notify the attending physician, explain the circumstances and available options, and obtain a new order while discontinuing the non-available medication. These established procedures were not followed when the staff borrowed one resident’s controlled medication and administered it to another resident.
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