Abrupt Discontinuation of Clonazepam Results in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder and major depressive disorder, who had been receiving clonazepam for anxiety, did not receive the medication for several days due to abrupt discontinuation. The resident's medication orders were changed multiple times as part of a gradual dose reduction (GDR) plan, but after the last order was discontinued, there was a gap from the evening of 5/16/2025 through 5/19/2025 during which the resident did not receive any clonazepam. The resident reported increased anxiety and worsening hand tremors during this period. Interviews with facility staff and medical providers revealed a lack of clear communication and follow-up regarding the GDR plan and the resident's medication needs. The psychiatric provider who initiated the GDR was no longer assigned to the resident and did not reassess the resident after the dose reduction. The medical director was not notified of the missed doses until several days later, at which point a new order for a lower dose was provided. The facility was unable to provide evidence that the resident remained free from significant medication errors, as the abrupt discontinuation of clonazepam occurred without appropriate oversight or a proper GDR process.