Failure to Prevent Significant Medication Error for Seizure Disorder
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder and traumatic brain injury did not receive two out of three scheduled doses of the anticonvulsant medication Keppra (Levetiracetam) as ordered. The medication was not administered on two occasions: once because the resident was lethargic and staff felt it was unsafe to administer, and once because the resident refused by keeping his mouth closed. Documentation shows that staff did not make multiple attempts to administer the medication, nor did they notify the provider or responsible party of the missed or refused doses, as required by facility policy. The resident was categorized as severely cognitively impaired and nonverbal, with a care plan indicating the need for seizure medication as ordered and monitoring for side effects and effectiveness. Despite this, staff did not follow up with additional attempts to administer the medication or escalate the issue to medical providers or the resident's representative. The lack of notification and follow-up led to the resident missing critical doses of his seizure medication. Subsequently, the resident experienced a seizure, which was documented by staff and confirmed by hospital records showing an undetectable Keppra level. Interviews with staff and medical providers confirmed that the missed doses and lack of notification were not in accordance with facility policy and expectations for care of residents with seizure disorders. The incident was self-reported by the facility, and staff interviews indicated knowledge of the policies, but these were not followed in this instance.