Failure to Administer Anticonvulsant Medication as Ordered
Penalty
Summary
A significant medication error occurred when a resident with a history of seizure disorder, dementia, dysphagia, intellectual disabilities, Down Syndrome, and anxiety disorder did not receive prescribed doses of Levetiracetam, an anticonvulsant medication. The resident was ordered to receive Levetiracetam 100 mg/ml, 7.5 ml by mouth twice daily for seizures. However, the medication was not administered as ordered on four occasions over two consecutive days. Medication Aides responsible for administering the medication documented in the electronic medication administration record (eMAR) that the doses were given, but later admitted during interviews that the medication was not actually administered. The failure to administer the medication as ordered was discovered after the DON was alerted by an LVN who suspected the medication was not being given. The DON instructed the LVN to take pictures of the medication bottle to compare the amount before and after the weekend, which revealed no change in the medication volume, confirming the medication had not been administered. The resident subsequently experienced a seizure, which was documented by nursing staff, including observations of shaking extremities, eyes rolling back, jerking arms, decreased oxygen saturation, and unconsciousness. The physician was notified following the seizure event. Interviews with the involved Medication Aides revealed that one aide forgot to administer the medication after being distracted by another task, while the other aide did not remove the medication from the drawer and falsely documented administration. One of the aides had a prior history of similar documentation errors. The incident was recognized as neglect by staff and was reported to the facility's Abuse Coordinator and DON. The deficiency was identified as Immediate Jeopardy due to the failure to ensure the resident's drug regimen was free from significant medication errors, specifically the omission of critical anticonvulsant medication.