Failure to Provide Physician-Ordered Medications Resulting in Increased Seizure Activity
Penalty
Summary
The facility failed to ensure that a resident with a history of traumatic brain injury, seizures, general anxiety, and aphasia received physician-ordered anti-convulsant and anti-anxiety medications for three consecutive days following admission. The resident was dependent on staff for most activities of daily living and was nonverbal with severe cognitive impairment. Despite clear physician orders for multiple medications, including Phenobarbital, Ativan, Vimpat, Dilantin, and olanzapine, the medication administration record (MAR) and progress notes indicated that these medications were not available and were not administered as ordered. During the period in question, the MAR showed that several doses of the prescribed medications were missed, and there was no documentation of any steps taken by staff to resolve the unavailability of the medications. There was also no evidence that the pharmacy, physician, responsible party, or facility administration were notified about the missing medications. The facility's Director of Nursing (DON) confirmed that she was unaware of the issue until after the resident experienced increased seizure activity and was sent to the emergency room. The DON also stated that there was no formal investigation or additional staff training following the incident, and she was unable to locate documentation reflecting any attempts to address the medication access problem. Progress notes documented that the resident experienced multiple seizures during the period when medications were not administered, leading to a transfer to the hospital for evaluation and treatment. Interviews with facility leadership revealed a lack of specific policies regarding actions to take when medications are unavailable, and there was no documentation to substantiate the administration of certain doses. The facility did have a general policy on medication administration, but it did not address the specific situation of missing medications.