Failure to Administer Anti-Seizure Medication as Ordered
Penalty
Summary
A resident with a history of seizures and respiratory failure was admitted to the facility with a physician's order for felbamate, an anti-seizure medication, to be administered twice daily. Despite this order, the medication was not administered for three days, resulting in five missed doses, due to complications in obtaining the medication from the pharmacy. Progress notes indicated staff were aware of the delay, but the medication was not delivered until several days after the order was written. Interviews with facility staff revealed that orders were not reviewed as required, and there was a lack of oversight in ensuring the medication was obtained and administered as prescribed. Staff also confirmed that when the Resident Care Manager was unavailable, other staff did not review new admission medications, contributing to the delay.