Failure to Administer Seizure Medications as Ordered
Penalty
Summary
A significant medication error occurred when a resident was admitted to the facility with physician's orders for multiple seizure medications, including Keppra, Vimpat (Lacosamide), and Zonisade. The facility failed to administer these medications as ordered, resulting in the resident missing one dose of Keppra, three doses of Vimpat, and two doses of Zonisade. The resident had a medical history of metabolic encephalopathy, seizure disorder, and status epilepticus, and was admitted following a hospital discharge. The failure to provide the prescribed seizure medications was due to several factors. The medications Vimpat and Zonisade were not delivered by the pharmacy, and there was no hard script sent from the hospital for Vimpat. The Keppra was delivered late in the evening, after the scheduled administration time. Nursing staff did not promptly notify the provider about the unavailability of the medications, and the required medication reconciliation and provider communication were not completed in a timely manner. The DON and LPNs involved confirmed that the missed doses were not identified or communicated to the provider until after the resident had already missed several doses. As a result of the missed doses, the resident experienced seizure activity and was found unresponsive with seizure-like activity by staff after a family member alerted them. The resident had a total of six seizures, each lasting one to three minutes, and was subsequently transported to the hospital. Interviews with facility staff and the nurse practitioner revealed that there was a lack of timely communication regarding the missing medications and the need for provider intervention, which contributed to the resident's adverse event.