Failure to Monitor Clozaril Serum Levels as Ordered
Penalty
Summary
The facility failed to follow a physician's order to obtain monthly Clozaril (clozapine) serum levels for a resident diagnosed with schizoaffective disorder and post-traumatic stress disorder. The resident had an active order for Clozaril 400 mg at bedtime to address auditory hallucinations, with a corresponding order to monitor Clozaril blood levels monthly. However, the facility did not obtain or have records of the required Clozaril serum levels for two out of five months reviewed. Interviews with the Director of Nursing confirmed the absence of Clozaril blood level results for the specified months. Additionally, a review of the facility's policy on antipsychotic medications revealed that it did not address the monitoring of Clozaril serum levels or outline a process for adequate monitoring of antipsychotic usage.