Failure to Administer Anti-Epileptic Medication as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer a prescribed dose of Keppra (levetiracetam), an anti-epileptic medication, to a female resident with a history of cerebral palsy, epilepsy, and severe cognitive impairment. The resident was dependent on all activities of daily living and had a care plan in place requiring seizure medication to be given as ordered. During a medication pass, the nurse administered lactulose instead of Keppra, then incorrectly documented that the Keppra had been given and failed to document the administration of lactulose. The error was discovered after the nurse reviewed the medication administration record (MAR) and realized the mistake. Interviews with the nurse and multiple members of the nursing leadership confirmed that the nurse did not follow the facility's policy requiring verification of the five rights of medication administration. The nurse acknowledged the error, stating she was unsure why it occurred and that she may have been nervous. The facility's policy required checking the medication label three times to ensure correct administration, which was not done in this instance. The incident was identified through observation, record review, and staff interviews.