Failure to Obtain and Provide Ordered Controlled Medication for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that a prescribed controlled medication, clonazepam 0.5 mg, was available for a resident with Parkinsonism, anxiety disorder, and non-Alzheimer’s dementia with behavioral disturbance. The resident was admitted with a hospital discharge order for clonazepam 0.5 mg PO daily PRN for anxiety, and the facility’s physician orders dated 02/14/2026 reflected clonazepam 0.5 mg every 24 hours PRN for anxiousness related to anxiety disorder for 14 days. The resident’s MDS showed moderate cognitive impairment (BIMS score of 9) and active diagnoses of non-Alzheimer’s dementia and anxiety disorder. Despite these orders, the contracted pharmacy confirmed that no prescription for clonazepam was received before 02/20/2026, and the medication was not delivered to the facility until 02/21/2026. During this period without the ordered clonazepam available, documentation showed behavioral issues. A CNA note from 02/17/2026 at 02:00 a.m. described the resident as agitated and hitting staff, which triggered an alert on the facility’s EMR dashboard and was discussed in the morning clinical meeting. On 02/20/2026 at 03:33 a.m., an RN documented that the resident was combative with care, had smeared bowel movement on himself and the bed, and that although there was an order for clonazepam 0.5 mg PRN, there was “no script”; the pharmacy was called and the primary physician was made aware. A psychiatric ARNP visit on 02/20/2026 noted the resident was being followed for psychotropic medication management due to dementia with inappropriate behavior and resistance to ADL care at night, and the plan was to continue clonazepam 0.5 mg PO every 24 hours PRN for 14 days as currently prescribed. The facility’s own policy required compliance with all laws and requirements related to handling and documentation of controlled substances, yet the ordered controlled medication was not obtained and available for use until several days after admission.
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