Failure to Administer Prescribed Medications to Hospice Resident
Penalty
Summary
A hospice resident admitted for a respite stay was not administered prescribed anticonvulsant medication (levetiracetam/Keppra) and insulin as indicated in the hospice records and provided by the family. Upon admission, the resident's history and physical, including a medication list, were uploaded to the electronic medical record, but staff failed to ensure the medications were located or administered. Nursing staff did not document attempts to find the resident's home medications, notify the physician or hospice provider about missing medications, or order the necessary medications from the pharmacy, despite having the medication list available. The resident, who had a complex medical history including epilepsy, diabetes, and cognitive impairment, did not receive any of his prescribed medications during his stay. Staff relied on the expectation that the resident's daughter would bring the medications, but when this did not occur, no further action was taken to obtain or administer the required drugs. Communication with the hospice provider and family was attempted, but there was no follow-up to ensure medication administration, and the medications were later found in the resident's belongings after the incident. As a result of not receiving his anticonvulsant medication, the resident experienced a seizure and required hospitalization. Hospital records confirmed the resident had not received his medications for over 36 hours, and both the facility's nurse practitioner and pharmacists confirmed that missing doses of Keppra could result in breakthrough seizures. The facility's own policy required medications to be ordered from the pharmacy if not supplied by the family, but this was not followed.