Failure to Provide Timely Pharmacy Services for Seizure Medications
Penalty
Summary
The facility failed to ensure timely delivery and administration of prescribed seizure medications for a resident, as required by physician orders and facility policy. The resident had documented orders for Lamotrigine and Lacosamide to be administered at specific times for seizure management. On the evening of August 9, 2025, the resident did not receive the 9:00 p.m. doses of both Lamotrigine and Lacosamide because the medications were not delivered by the facility's pharmacy. This omission was confirmed by review of the Medication Administration Record (MAR) and a nursing note, which documented that the resident did not receive the prescribed seizure medications during the overnight shift. Facility policy, revised in April 2019, requires that pharmacy services be available 24/7 to ensure residents have a sufficient supply of prescribed medications and receive them in a timely manner. Despite this policy, the resident's seizure medications were not available for administration as ordered, and the DON confirmed the failure was due to the pharmacy not delivering the medications. The physician was notified of the missed doses, as documented in the nursing note.