Failure to Administer and Track Seizure Medication Leads to Missed Doses and Seizure
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, profound intellectual disabilities, and epilepsy did not receive her prescribed Carbamazepine as ordered. The resident, who was non-verbal, dependent on staff, and received all medications via g-tube, had her medication packets found unopened and stored in a bin for destruction rather than being administered. Multiple unopened medication packets for this resident were discovered in the medication cart and later in the DON's office, with dates indicating they should have been given. Despite these findings, the medication administration record (MAR) was marked as if the medication had been given. Nursing staff, including RNs and LVNs, reported finding these unopened medication packets on several occasions and brought the issue to the attention of the DON. However, the DON did not investigate further, relying on the MAR documentation and dismissing concerns because the resident had not recently had a seizure, according to her knowledge. There was also a lack of communication between shifts, and some staff admitted to removing unopened medication packets without reporting the issue. The pharmacy confirmed that no extra medication was sent, and the medication packets matched the physician's orders. The facility did not have a system in place to document or track the destruction of non-controlled medications, including the resident's Carbamazepine. When asked for records of destroyed medications, the DON was unable to provide documentation, stating that it was no longer required. The facility's policies required proper administration and investigation of medication errors, but these procedures were not followed, resulting in the resident missing doses of her seizure medication and experiencing a seizure episode.