Failure to Clarify and Follow Physician Order for Keppra Results in Harm
Penalty
Summary
A significant medication error occurred when a resident with a history of traumatic brain injury, chronic kidney disease stage 3, heart failure, and dysphagia was prescribed Levetiracetam (Keppra) for 7 days as seizure prophylaxis following hospital discharge. The facility failed to clarify, accurately transcribe, and follow the physician's order, resulting in the resident receiving Keppra for an extended period beyond the intended 7 days. The hospital discharge summary and related documentation repeatedly indicated that Keppra was to be administered for only 7 days, but the facility continued administration for approximately two weeks longer than prescribed. During this period, the resident exhibited a decline in condition, including increased lethargy, decreased appetite, weight loss, and reduced participation in therapy. Family members raised concerns about the resident's lethargy and possible side effects of Keppra, but the medication was only tapered and not discontinued until much later. The resident's condition continued to deteriorate, leading to a hospital readmission where acute metabolic encephalopathy, aspiration pneumonia, and acute kidney injury were diagnosed. Hospital records specifically noted that the continued use of Keppra was a contributing factor to the resident's encephalopathy, and the medication was discontinued during the hospital stay. The facility's process for entering and verifying new medication orders involved multiple staff members, but there was a failure to clarify the duration of the Keppra order despite clear indications in the hospital documentation. Interviews with facility staff revealed a lack of thorough review and understanding of the discharge instructions, and no documentation of a thorough investigation into the medication error was provided. The facility's own policy defined medication errors as preventable events that may cause harm, yet the error was not recognized or reported by staff until it resulted in actual harm to the resident.