Failure to Administer Anti-Convulsant Medications as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered by the physician. The resident's medication orders included Oxcarbazepine 300 mg in the morning and evening, and Lamotrigine 400 mg once daily. Review of the Medication Administration Record (MAR) for the month showed multiple missed doses of both Oxcarbazepine and Lamotrigine on specific dates, with documentation confirming that the medications were not administered as prescribed. Interviews with nursing staff revealed that the missed doses were due to the unavailability of the medications at the facility. Nurses reported that they contacted the pharmacy for delivery, but the medications were not delivered in time for administration. The staff acknowledged that missing doses of anti-convulsant medications could place the resident at risk for seizures, and that a certain blood level of these medications is required to prevent such events. The Director of Nursing confirmed that the medication errors were a result of delayed medication deliveries from the pharmacy, which prevented timely administration according to physician orders. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, but this was not followed due to the lack of medication availability.