Failure to Administer Seizure Medication During NPO Status
Penalty
Summary
The facility failed to ensure that a resident with a history of seizures and glioblastoma received their prescribed Keppra (an anti-seizure medication) when placed on NPO status for a scheduled abdominal CT scan. The resident was scheduled to receive Keppra twice daily, but did not receive the 9:00 a.m. dose after being made NPO. There was no documented communication between nursing staff and the physician regarding alternative routes of administration, nor was there clarification with the pharmacy about the medication order. The resident ultimately went over 12 hours without receiving Keppra. Interviews with nursing staff and the Director of Nursing confirmed that the facility had the capability to administer IV medications and that seizure medications could be given in the facility. The medical record showed that an order for IV Keppra was present, but it was not administered before the resident was transferred to the hospital later that day. There was no documentation of any interventions, communication with the physician, or pharmacy regarding the missed dose, despite facility policy requiring such documentation.