Significant Medication Error Leads to Resident Seizures and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with epilepsy and dementia did not receive prescribed anti-seizure medications (levetiracetam, lamotrigine, and zonisamide) at the scheduled time. The physician's order required these medications to be administered twice daily at 8:00 AM and 8:00 PM. On one occasion, an LPN administered the medications significantly late, at approximately 10:30 PM, and did not document the administration until 11:47 PM. Prior to this incident, the resident had no recorded seizures in the facility. Following the late administration, the resident experienced multiple seizures, including one lasting about ten minutes, and was subsequently sent to the hospital via ambulance. The DNS became aware of the incident after a family member raised concerns about the timing of medication administration. The DNS confirmed that timely administration of anti-seizure medications is important and noted that the facility was not conducting routine lab monitoring for levetiracetam levels. No incident report was completed, and the DNS did not discuss the event with the LPN involved.