Failure to Administer Ordered Anticonvulsant Medication and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for a resident who was non-verbal, had Down's Syndrome, was dependent for all care needs, and relied on a PEG tube for nutrition and medication administration. The resident had physician orders for Dilantin Oral Suspension to be given twice daily via PEG tube, and for Phenytoin Oral Tablet to be given via PEG tube every 12 hours as needed if the liquid Dilantin was unavailable. Record reviews revealed that there were multiple instances in March and April where Dilantin was not administered as ordered, with documentation on the Medication Administration Record (MAR) indicating 'drug not available' or referencing nurse notes, and with no documentation that Phenytoin was administered as an alternative during these periods. Communication with the pharmacy confirmed that neither Dilantin nor Phenytoin was available for several days, and there was no evidence that the physician was notified within 24 hours of the medication being unavailable, as required by facility policy. Progress notes and MARs lacked documentation of administration or physician notification for the missed doses. The resident was subsequently hospitalized due to a seizure, with hospital records indicating low Dilantin levels and a new order to increase the medication. Interviews with the DON and Administrator confirmed the lack of documentation for medication administration and physician notification during the periods when the medication was unavailable. Facility policy required provider notification and completion of a SAFE Event Report for medication errors, but these actions were not documented as completed.