Failure to Follow Physician Orders for Medication Changes
Penalty
Summary
A resident with diagnoses of epilepsy with partial seizures and dementia returned from a neurologist appointment with new physician orders to discontinue Levetiracetam and begin Lacosamide for seizure management. The nurse on duty was responsible for reviewing the progress note, transcribing the new orders onto the physician order form and Medication Administration Record (MAR), and notifying the pharmacy. However, the order to discontinue Levetiracetam and start Lacosamide was not promptly transcribed onto the MAR, resulting in Lacosamide not being administered for several days after the order was written. During this period, Levetiracetam continued to be administered to the resident without a valid physician order, as the discontinuation order was not recognized or acted upon. The error was only identified several days later, after which the medication administration was corrected. The facility did not have a written policy for following physician orders, but nurses were expected to follow such orders as part of their nursing practice.