Incomplete and Inaccurate Documentation of Seizure Medication Discontinuation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident regarding the discontinuation of a seizure medication, Keppra. On 2/12/25, a nurse entered a verbal order to discontinue Keppra in the resident's record, but did not document which provider gave the order or the rationale for discontinuation. The nurse later stated that a nurse practitioner had provided the verbal order due to the absence of a definite epilepsy diagnosis and a therapeutic Keppra level, but this reasoning was not recorded in the resident's chart. Additionally, a physician's progress note dated 2/24/25 inaccurately listed Keppra as an active medication, despite the medication having been discontinued earlier. The physician confirmed that the rationale for discontinuation should have been documented by the provider or the nurse who received the order.