Failure to Administer Anticonvulsant as Ordered Leads to Seizure and Hospitalization
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one of seven sampled residents reviewed for significant medication errors. Specifically, a resident with a history of seizures, chronic kidney disease, dependence on dialysis, hypothyroidism, cardiomegaly, and atherosclerotic heart disease had a physician order for Levetiracetam 500 mg to be given every 12 hours for seizure control. The medication administration record showed that 9 out of 26 morning doses of Levetiracetam were missed over a period of less than a month. As a result of these missed doses, the resident experienced seizure activity and required emergency department intervention, where IV Levetiracetam was administered. Documentation indicated that the resident returned from the hospital after receiving treatment for seizures, and it was noted that future medication administration would be adjusted to occur prior to dialysis. The DON was not aware of the reason for the resident's emergency room visit or the significant medication error at the time of the incident.
Removal Plan
- Regional Nurse Consultant will educate the Director of Nursing on identification of significant medication errors and administration of medication per physician orders.
- Director of Nursing/Designee will educate all licensed nurses and certified medication aides regarding administering medication according to physician orders and identification of significant medication errors.
- Medication aides and Licensed nurses will document medication administration in the eMAR.
- Any licensed nurse or certified medication aide not educated will not be allowed to work until they have received education.
- An audit of current residents missing significant medications for the last 7 days was conducted and completed by nursing management to assure that significant medications are given as ordered by physician.
- Any significant medication errors found during the audit will be reviewed by the Director of Nursing.
- The medical director will be notified of the findings for any further recommendations.