Failure to Ensure Consistent Administration of Seizure Medications
Penalty
Summary
A resident with a history of post-traumatic seizures, COPD, major depressive disorder, anxiety, and traumatic brain injury experienced a significant medication error related to the administration of seizure medications. On the morning of the incident, the resident exhibited unusual behavior by requesting to return to bed after breakfast, which was not typical for him. Shortly after being transferred to bed, the resident began experiencing seizure activity, prompting staff to call emergency services. Review of the resident's medication administration records (MAR) for June and July revealed multiple missed doses and refusals of prescribed seizure medications, including Phenytoin, Divalproex, Levetiracetam, and Aptiom. The medication cards also showed discrepancies between the number of tablets dispensed and those remaining, indicating that several doses were not administered as ordered. Interviews with nursing staff confirmed that the resident could be non-compliant with medication administration depending on his mood, and that staff would attempt to re-approach him if he initially refused. However, documentation practices were inconsistent, with staff acknowledging that if a medication was not signed off in the MAR, it was not given. The facility's policy required physician notification if three consecutive doses or a pattern of frequent refusals occurred, but there was no documentation of such notifications or grievances related to the resident's medication administration. The failure to ensure consistent administration and documentation of seizure medications resulted in a significant medication error for the resident.