Failure to Administer Anti-Seizure Medication Results in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy was admitted to the facility and did not receive their prescribed anti-seizure medication, Lacosamide, as ordered. The resident's medication orders included Lacosamide 200 mg to be administered orally every 12 hours, but review of the medication administration record showed that the medication was not given from the time of admission through several days following. The care plan for the resident specifically identified the risk for seizure activity and included interventions to medicate as ordered and assess for effectiveness and adverse effects. The failure to administer the anti-seizure medication was due to a breakdown in the medication reconciliation and procurement process. Upon admission, the resident's seizure medication was not available at the facility, and staff did not ensure its timely delivery or obtain it from alternative sources. The pharmacy was unable to fill the prescription because it had already been filled by the previous facility, and attempts to obtain the medication from the prior facility were unsuccessful. Staff did not notify the provider or take further steps to secure the medication, and the lack of communication and follow-up resulted in the resident not receiving the necessary treatment. As a result of not receiving the prescribed anti-seizure medication, the resident experienced multiple seizures and required transfer to the hospital. Hospital records confirmed that the resident had not received Lacosamide for several days prior to the seizure event, and that the resident's seizures had previously been stable for the past year. Interviews with facility staff confirmed that the omission of the medication was not identified until after the resident was hospitalized for seizure activity.