Failure to Administer Prescribed Anti-Seizure Medication and Notify Physician
Penalty
Summary
The facility failed to administer a resident's prescribed anti-seizure medication, Levetiracetam, as ordered by the physician, resulting in nine out of ten missed doses over a five-day period. Documentation in the resident's medical record indicated that the medication was not available to staff, and there was no evidence that the physician or the Director of Nursing (DON) was notified of the missed doses. The facility's medication administration policy required that discrepancies with medication orders or supplies be reported to the nurse manager, and that the e-kit, which contained an emergency supply of Levetiracetam, be used in such situations. However, staff did not utilize the e-kit or follow the notification procedures outlined in the policy. The resident, who had a history of diabetes, stroke, and Moyamoya Disease, had a physician order for Levetiracetam 500 mg twice daily. The resident reported going without the seizure medication for almost a week, expressing fear of experiencing another seizure, especially given a recent diagnosis of a seizure disorder that had previously led to a heart attack. The resident and a family member both reported making multiple requests for the medication and seeking information from facility staff, but were only told that the issue was being addressed, without specifics or resolution until after the missed doses. Interviews with facility staff and pharmacy representatives confirmed that the medication was not administered due to it being unavailable, and that the pharmacy had last delivered a 30-day supply several days prior to the missed doses. Staff acknowledged that the e-kit contained an emergency supply of the medication and that procedures required immediate re-ordering and notification of the DON when medications were missing. Despite these protocols, the necessary steps were not taken, resulting in the resident missing nearly all scheduled doses of a critical medication over several days.