Failure to Provide and Document Essential Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure that pharmacy services provided necessary medications for a resident with Down's Syndrome, who was non-verbal, dependent for all care needs, and fully reliant on PEG-tube feedings. The resident was prescribed Dilantin Oral Suspension to be administered twice daily via PEG-tube, with Phenytoin Oral Tablet as an alternative if the liquid form was unavailable. Review of the Medication Administration Record (MAR) and progress notes revealed multiple instances in March and April where Dilantin was not available or not administered, and there was a lack of documentation for both Dilantin and Phenytoin on several dates. Communication records showed that the pharmacy confirmed Dilantin and Phenytoin were not available for delivery over several days. Although a nurse contacted the pharmacy regarding the medication shortage, there was no evidence that the physician was notified within 24 hours as required by facility policy. Additionally, there was insufficient documentation in the MAR and progress notes regarding the administration or non-administration of the medications during the identified periods. The resident was subsequently hospitalized due to a seizure, with hospital records indicating low Dilantin levels and a new order to increase the medication dosage. Facility interviews confirmed the absence of documentation for medication administration and the lack of timely physician notification about the unavailability of the prescribed medications.