Failure to Prevent Significant Medication Error Due to Lack of Updated Medication List
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anoxic brain damage, anxiety, and epilepsy was admitted to the facility without the hospital's updated medication discharge list. Despite the hospital's instructions to discontinue clonazepam, Keppra, Seroquel, and valproic acid, the facility continued to administer these medications according to previous physician orders. Specifically, clonazepam and Seroquel were administered on the day after admission, and Keppra and valproic acid were administered for several days following admission. The nurse practitioner was unaware of the hospital's instructions to discontinue these medications and only adjusted the orders after concerns were raised by the resident's family. The nurse practitioner also reported repeatedly reminding nursing staff to obtain the updated medication list from the hospital. During this period, the resident was noted to be lethargic while awaiting the correct medication list, indicating that the facility failed to ensure the resident was free from significant medication errors.