Corewell Health Rehabilitation & Nursing Center gave Lorazepam to Resident 101, a female with severe late-onset Alzheimer's dementia, beginning in May. The facility prescribed the sedative for insomnia and anxiety without informing her family or obtaining required consent for psychotropic medication use.
The resident's family member, who holds durable power of attorney, learned about the Lorazepam only when her relative was admitted to the hospital on June 8 after a fall. Hospital staff informed the family that the resident had been receiving the medication nightly.
"She was not aware Resident 101 had been receiving that medication," the family member told inspectors. She said she never gave permission for the Lorazepam and felt her relative should not have been prescribed the drug because "Resident 101 was so mobile."
The facility had escalated the medication regimen over several weeks. Orders show Lorazepam was first prescribed on May 9 as a 0.5 mg tablet to be taken nightly for insomnia. By May 29, staff added a daytime dose for anxiety. On June 4, just four days before the fall, the facility changed the prescription to 0.25 mg three times daily as needed for anxiety.
No care plans addressed the use of psychotropic medications or monitoring for adverse consequences, inspection records show.
Social Worker H told inspectors the facility had multiple methods for obtaining medication consent. Decision makers could sign electronically when residents were admitted or when medication changes required consent. Staff could also call decision makers for verbal permission with two witnesses present, or mail consent forms for signature with social work follow-up.
But none of these procedures were followed for Resident 101's Lorazepam prescriptions.
A psychotropic medication consent form dated April 17 contained no signature and no consent for the Lorazepam orders. The document only showed the family member as a participant as of September 25, months after the medication was started. The facility provided no documentation of verbal consent.
"SW H was unable to locate notes for Resident 101 as well as notes which had indicated a conversation had been had with the decision maker for the prescribed lorazepam medications," inspectors wrote.
Nurse Liaison C confirmed during interviews that no documentation existed in the resident's record showing verbal consent was received for Lorazepam.
Social Worker H acknowledged the facility lacked standardized corporate procedures for obtaining medication consents. The absence of clear protocols contributed to the consent failure that left the family uninformed about their relative's psychotropic medication treatment.
Federal regulations require nursing homes to ensure residents and their representatives are fully informed about health status, care and treatments. The informed consent requirement allows families to weigh the risks and benefits of medications and consider alternative treatment options.
Lorazepam belongs to a class of drugs called benzodiazepines, which can increase fall risk and confusion in elderly patients, particularly those with dementia. The medication's sedating effects may have contributed to mobility issues that the family member specifically cited as a concern.
The resident was admitted to Corewell Health with multiple diagnoses including severe Alzheimer's dementia with agitation, a ground-level fall, insomnia and depression. Her complex medical needs required careful medication management and family involvement in treatment decisions.
The facility's failure extended beyond missing paperwork. Staff administered psychotropic medication for months while family members remained unaware their relative was receiving daily sedatives. The consent violation prevented the family from participating in critical decisions about medication risks and benefits.
Inspectors found the violation created minimal harm or potential for actual harm to the resident. However, the family's discovery of unauthorized medication use only after a hospitalization highlighted the facility's systematic failure to involve decision makers in treatment choices.
The inspection revealed broader problems with the facility's medication consent processes. Without standardized procedures or proper documentation, other residents may have received psychotropic medications without appropriate family involvement or informed decision-making.
The case demonstrates how administrative failures can undermine family participation in nursing home care decisions, particularly for residents with dementia who cannot advocate for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Corewell Health Rehabilitation & Nursing Center - from 2025-10-01 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Corewell Health Rehabilitation & Nursing Center -
- Browse all MI nursing home inspections