Failure to Administer Ordered Anticonvulsant Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with a history of seizures and other complex medical conditions was re-admitted to the facility from an acute care hospital. Upon re-admission, the hospital's medication reconciliation report included new orders for Keppra, an anticonvulsant, and cephalexin, an antibiotic. However, these new medication orders were not entered into the facility's electronic medical record (EMR) and were not included in the resident's Medication Administration Report (MAR) from the time of re-admission through the date the resident was sent back to the hospital. Documentation by the receiving LPN did not indicate that new orders were verified with the physician, and the facility's process for double-checking and entering new orders was not followed as described in interviews with the ADON and DON. As a result of not receiving the prescribed anticonvulsant medication, the resident experienced seizure activity and required rehospitalization. The facility's policies required that new and readmission medication orders be clearly documented, verified, and entered into the EMR, but these steps were not completed for this resident. Interviews with staff revealed assumptions and gaps in communication regarding the entry and verification of new orders, contributing to the medication omission and subsequent harm to the resident.