Failure to Notify Physician of Missed Epilepsy Medication Doses
Penalty
Summary
Facility staff failed to ensure timely physician notification when there was a significant change in a resident's physical status, specifically regarding missed doses of a prescribed epilepsy medication. The resident, an older adult with diagnoses including encephalopathy and epilepsy, was re-admitted to the facility and required supervision for care. Physician orders indicated the resident was to receive Lamotrigine 250 mg twice daily for epilepsy management, but approximately 10 scheduled doses were missed over a documented period. Medication aides reported that the medication was not available in the cart and stated they informed the charge nurses (LVNs) on duty about the issue. However, the charge nurses did not escalate the matter or notify the resident's physician about the missed doses. The physician later confirmed she was not informed of the medication disruption until after the issue was resolved, despite her expectation to be notified of any missed medications for prompt intervention and resident safety. The Director of Nursing (DON) and the facility administrator both stated that their expectations for staff conduct were not met, as the nurses failed to notify the provider of the missed medication doses. The issue with medication availability was related to an outstanding pharmacy balance, which delayed access to the medication. The facility's policy required notification of the physician when medications were unavailable and missed doses occurred, but this protocol was not followed in this instance.