Failure to Identify Missing Stop Date for PRN Clonazepam Order
Penalty
Summary
A deficiency occurred when the facility and its consultant pharmacist failed to identify and report that a resident was receiving clonazepam, a controlled medication, without a specified duration of treatment or a stop date. The medication order, which was written as a PRN (as needed) for anxiety-related behaviors, was initiated without a discontinuation date and continued beyond the recommended timeframe. The facility's policies required that PRN psychotropic medications have a specific duration, typically 14 days, and that any continuation beyond this period be justified by the prescriber. However, the order for clonazepam remained active without such documentation or review. Interviews with facility staff, including a Licensed Vocational Nurse, the consultant pharmacist, and the Director of Nursing, confirmed that the lack of a stop date or duration for the PRN clonazepam order was not identified during the monthly medication regimen review. The resident involved had significant cognitive and functional impairments, requiring extensive assistance with activities of daily living and was not capable of making medical decisions. The facility's policy on medication regimen review emphasized the need for comprehensive monthly reviews to prevent or minimize adverse consequences, but this process failed to detect the irregularity in the resident's medication order.