Significant Medication Error Due to Missed Anticonvulsant Doses
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, seizures, and nontraumatic intracerebral hemorrhage was not administered two consecutive doses of a prescribed anticonvulsant medication, Lacosamide, following readmission to the facility. The resident's medication administration records showed missed doses on two occasions, and interviews with nursing staff revealed that the medication was not available on hand and that there was a discrepancy between the ordered tablet form and the available liquid form. The agency nurse entered incorrect medication administration times, and the issue was not resolved in time to administer the missed doses. Following the missed doses, the resident exhibited seizure-like activity, including facial twitching and head turning, which prompted notification of the nurse practitioner and subsequent transfer to the emergency department. Hospital records indicated the resident was admitted for acute hypercapnic and hypoxemic respiratory failure, acute metabolic encephalopathy, and seizure disorder. The medical director confirmed that the missed doses of Lacosamide could have contributed to the resident's seizure activity. Record reviews and staff interviews confirmed that the medication error resulted from failures in medication order entry, communication regarding medication availability, and timely notification of providers. The facility's policy required that medications be administered as prescribed and that staff be properly oriented to the medication distribution system, but these procedures were not followed, leading to the significant medication error.