Failure to Administer and Reconcile Clonazepam per Orders and Controlled Substance Policy
Penalty
Summary
The deficiency involves the facility’s failure to administer and reconcile a controlled medication, clonazepam, according to physician orders and facility policy for one resident. The resident was admitted with diagnoses including encephalopathy, low back pain, cervical spinal stenosis, and anxiety, and had a care plan identifying increased risk of adverse reactions related to opiate use, with interventions to administer medications as ordered and monitor for side effects. The admission MDS showed intact cognition. Physician orders for February directed clonazepam 0.5 mg PO BID for anxiety. Review of the MAR/TAR showed that multiple scheduled doses (one morning dose on the first day of the month, both morning and evening doses on the second day, and both morning and evening doses on the sixteenth day) were marked with a code indicating “Other/See Nurses Notes,” and the narcotic sign-out sheet showed no corresponding sign-outs for these doses. Progress notes lacked any entry for the missed dose on the first day, while notes on the second and sixteenth days documented that clonazepam was not administered due to awaiting medication from the pharmacy or a new prescription. The Interim DON confirmed that five doses were missed, contrary to the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed. The deficiency also includes improper handling and documentation of controlled substance wasting for the same resident’s clonazepam. The narcotic sign-out sheet showed clonazepam 1 mg available with an order for 0.5 mg BID, and entries on two consecutive days documented that RNs each wasted 0.5 mg of clonazepam but signed the waste with only a single signature and no second witness, despite facility policy requiring all controlled substance destruction to be witnessed by at least two nurses with both signatures recorded. The Interim DON confirmed that only one signature appeared for each waste event. One RN stated she always had a witness and speculated the other nurse may have walked away without signing, while the other RN reported she had not been aware at the time that two nurse witnesses and signatures were required. The facility’s controlled substance policy specified adherence to state and federal laws and required two licensed nurse witnesses and a record for each drug destruction, which was not followed in these instances.
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