Failure to Discontinue Medication as Ordered by Physician
Penalty
Summary
The facility failed to follow its Physician's Order Policy by not discontinuing a medication as ordered by the resident's neurologist. A resident with a diagnosis of symptomatic epilepsy and complex partial seizures was admitted with several anti-seizure medications, including Brivaracetam and Levetiracetam (Keppra). The neurologist communicated on multiple occasions, both by phone and fax, that Keppra should be discontinued because it should not be prescribed concurrently with Brivaracetam. Despite these communications, the medication administration records show that the resident continued to receive Keppra for several weeks after the discontinuation order was given. Interviews and record reviews revealed that the neurologist's office contacted the facility to clarify the medication list and specifically instructed discontinuation of Keppra. The Assistant Director of Nursing (ADON) stated that she did not recall receiving follow-up communication from the neurologist's office after sending the medication list, and there was no documentation that the discontinuation order was relayed to or verified with the attending physician. Progress notes did not reflect any action taken regarding the neurologist's order, and the resident continued to receive Keppra alongside Brivaracetam, contrary to the specialist's instructions.