Failure to Ensure Availability of Ordered Medication
Penalty
Summary
Facility staff failed to ensure that a resident's prescribed medication, Levetiracetam, was available for administration as ordered. The resident, who had multiple complex medical conditions including epilepsy, spastic quadriplegia, ventilator dependence, and a gastrostomy tube, had a physician's order for Levetiracetam solution to be administered every 12 hours via gastrostomy tube. Although the medication was reordered and delivered to the facility, a nurse was unable to locate it on any of the medication carts or in the medication room during a medication pass. The facility's policy required nurses to sign the packing slip upon delivery and place the medication on the correct cart, but the medication was not available when needed. During the medication pass, the nurse attempted to use another resident's Levetiracetam to administer the dose, which was stopped by the surveyor. The nurse acknowledged that using another resident's medication was not in accordance with facility policy and indicated she would notify the nurse practitioner to obtain an order for an alternative form of the medication. The unit manager confirmed that the medication had been signed for upon delivery and should have been placed on the correct cart, but could not explain why it was missing. The staff's actions resulted in the resident's medication not being available for administration as ordered.