Failure to Ensure Resident Received Prescribed Seizure Medication
Penalty
Summary
A deficiency occurred when a male resident with diagnoses of encephalopathy and epilepsy, who was severely cognitively impaired and dependent on staff for care, did not receive his prescribed Lamotrigine 250 mg twice daily for epilepsy management. Over a specified period, approximately 10 scheduled doses were missed, as documented in the Medication Administration Record (MAR) and confirmed by multiple medication aides. The medication was not available during this time, and the aides reported the issue to the charge nurses on duty. Despite being informed by the medication aides, the charge nurses did not escalate the issue to the Director of Nursing (DON) or notify the resident's physician about the missed doses. The physician was only informed after the issue was resolved, and she stated that consistent administration of the medication was critical for the resident's health and quality of life. The DON also confirmed that she was not notified of the medication issue until after several doses had been missed and that the nurses failed to follow the facility's policy regarding notification and escalation of medication availability issues. The underlying cause of the medication unavailability was an outstanding balance with the pharmacy, which resulted in the pharmacy withholding the medication until payment was received. The facility's policy required staff to notify the charge nurse, attempt to obtain the medication from an emergency kit, contact the pharmacy for a STAT delivery if needed, and inform the physician of any missed doses due to medication availability. These steps were not followed, leading to the resident missing multiple doses of a critical medication.