Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Phenobarbital for seizure control. The resident, who had diagnoses including epilepsy, left femur fracture, type 2 diabetes mellitus, and adult failure to thrive, had multiple missed doses of Phenobarbital as ordered by the physician. Review of the medication administration records (MAR) for May revealed nine missed morning doses and four missed bedtime doses, with documentation inconsistencies and incomplete nursing notes regarding the reasons for the missed doses. In several instances, the medication was not available in the facility, and pharmacy delivery delays or prescription issues were cited, but not always clearly documented. Observations confirmed that the medication was not present in the locked narcotic drawer during medication pass, and staff interviews revealed a lack of awareness and follow-up regarding the missed doses. The nurse practitioner was not informed of the extent of the missed doses and expressed concern, noting that the medication is critical for seizure prevention. Further review indicated that the medication was actually available in the facility's AlixaRX system and could have been administered, but this resource was not utilized by staff. Facility policy requires medications to be administered in accordance with physician orders and established schedules, but these protocols were not followed in this case. The resident's Phenobarbital blood level was found to be at the lower end of the therapeutic range, and the facility's own records showed that the medication was available but not accessed. The deficiency was substantiated by interviews, record reviews, and direct observation, confirming that the resident was not protected from significant medication errors as required.