Failure to Administer Correct Dosage of Anti-Epileptic Medication
Penalty
Summary
The facility failed to ensure that a resident received the correct dosage of levetiracetam (Keppra), an anti-epileptic medication, as ordered by the hospital physician. The resident, a female with a history of traumatic subarachnoid hemorrhage, unsteadiness on feet, and unspecified convulsions, was admitted with a care plan identifying her as at risk for wandering, falls, and elopement. On 10/09/2025, the hospital physician ordered an increase in the resident's levetiracetam dosage from 500 mg twice daily to 750 mg twice daily. However, facility records show that the order was not entered into the facility's electronic health record system, and the resident continued to receive the lower dose until 11/26/2025, when the correct dosage was finally administered. During this period, medication administration records confirm that the resident received only 500 mg of levetiracetam twice daily, despite the updated hospital order. Laboratory results taken during this time indicated that the resident's blood levels of levetiracetam remained within the therapeutic range. Observations and interviews with staff revealed that the resident was non-verbal, a constant wanderer, and had experienced a fall followed by convulsions. The nurse on duty at the time of the fall could not determine whether the seizure caused the fall or vice versa. The facility physician acknowledged that the order for the increased dosage was missed and not entered by the nursing staff. The facility's policy on medication errors, as referenced in the report, defines significant medication errors to include those involving drugs that require titration to specific blood levels, such as anticonvulsants. The failure to update and administer the correct dosage of levetiracetam as ordered constitutes a significant medication error, as it could have altered the resident's blood levels and affected seizure control. The deficiency was identified through observation, interview, and record review, confirming that the resident did not receive the prescribed medication regimen for an extended period.