Failure to Administer Anticonvulsant Medication and Protect Resident from Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder, dementia, intellectual disabilities, and other complex medical needs did not receive prescribed anticonvulsant medication (Levetiracetam) as ordered by the physician. The resident was non-verbal and required strict adherence to medication administration to prevent seizures. Despite a physician's order to increase the dosage due to previously low medication levels, the medication was not administered for four consecutive doses over a weekend. Medication Aides responsible for administering the medication failed to do so but documented in the electronic medication administration record that the medication had been given. The charge nurse reported concerns to the DON regarding the resident not receiving the anticonvulsant medication as ordered, based on low lab values. However, the DON did not immediately implement protective measures or initiate an investigation. Instead, the DON instructed the nurse to gather evidence by monitoring the medication bottle, delaying any intervention until after the weekend. During this period, the resident missed multiple doses of the critical medication, and no immediate steps were taken to ensure the resident's safety or to verify medication administration. As a result of the missed doses, the resident experienced a seizure, which was documented by nursing staff. The incident was not promptly reported to the facility administrator or to the state as required. Interviews with staff revealed a lack of immediate action and failure to follow facility policy regarding the reporting and investigation of neglect. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident from neglect and to ensure medications were administered as ordered.