Failure to Administer Prescribed Antiseizure Medication Due to Lapsed Prescription and Communication Gaps
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder and traumatic brain injury did not receive a prescribed twice-daily dose of an antiseizure medication, Lacosamide 50 mg, for seven consecutive days. The medication was not available due to an expired prescription, and multiple nursing staff documented the missed doses in the Medication Administration Record (MAR) but did not consistently notify the provider or pharmacy in a timely manner. Communication about the missing medication was fragmented, with some nurses leaving messages for the pharmacy or provider, while others assumed the issue had already been addressed by previous shifts. During this period, the resident continued to receive other antiseizure medications, including Lacosamide 200 mg, Levetiracetam, and Depakote, and did not exhibit any signs of seizure activity, agitation, or changes in vital signs. The resident and family were eventually notified about the missed doses, and the Medical Director was informed after several days, at which point a new prescription was sent to the pharmacy and the medication was delivered to the facility. Interviews with nursing staff, the Medical Director, and pharmacy personnel revealed that the lack of a systematic process for ensuring medication availability and prompt communication regarding missing medications contributed to the delay. Documentation in the MAR and communication logs showed that the issue persisted across multiple shifts, with inconsistent follow-up and escalation, resulting in a significant medication error for the resident.