F0658

E

Failure to Administer Anti-Seizure Medications as Prescribed

Mountain View, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were administered as prescribed and in accordance with professional standards for two residents receiving anti-seizure medications. For the first resident, admitted with epilepsy and on a titration schedule for lamotrigine, the hospital SNF orders dated 10/6/25 directed lamotrigine 25 mg, 2 tablets (50 mg) by mouth at bedtime for 5 days, with a detailed 8‑week up‑titration schedule. The facility’s clinical physician orders initially reflected lamotrigine 25 mg, 2 tablets at bedtime for 5 days, but this order was discontinued on 10/7/25. A new order dated 10/7/25 changed lamotrigine to 25 mg, 2 tablets in the morning for one week, with a start date of 10/8/25 at 9 a.m. The RN documented that admission orders and diagnoses were reviewed with the NP and updated, and the NP’s progress note stated to continue lamotrigine titration as recommended by neurology and to continue all home medications as prescribed by the discharging physician.

Review of the medication administration record for this resident showed lamotrigine 25 mg, 2 tablets was given on 10/6/25 at 9 p.m., but there was no documentation of administration on 10/7/25 or 10/8/25. The DON explained that when orders are changed in the EHR, the next dose starts the next day, and that the lamotrigine was scheduled for 10/8/25 at 9 a.m. but was not given because the resident was at therapy; the DON stated medications could be given within one hour before or after the scheduled time, and the resident should have received morning medications between 8 a.m. and 10 a.m. On 10/8/25, PT documentation indicated the resident consented to therapy between 10:15 a.m. and 10:30 a.m., and during use of an Omnicycle, jerky/dystonic movements worsened, therapy was stopped, nursing was notified, and a seizure was identified. A change in condition note documented that at approximately 10 a.m. the nurse went to administer morning medications but the resident was in therapy, and at approximately 10:50 a.m. the therapist reported the seizure, after which 911 was called and the resident was transferred to the hospital. A neurology consult from the hospital recommended facility education regarding the importance of not missing anti‑seizure medications and giving all as prescribed. The RN, NP, MD, DON, and consultant pharmacist each stated they were unsure why the lamotrigine timing was changed, and the consultant pharmacist stated that changes in medication administration timing should be ordered by a provider.

For the second resident, admitted with a wedge compression fracture and epilepsy and later readmitted after a hospitalization, the hospital SNF orders dated 10/20/25 specified lacosamide 150 mg, 1 tablet by mouth twice daily, with the last hospital dose given at 9:31 a.m. on 10/20/25. The facility’s physician orders contained two active lacosamide orders: one for 150 mg, 1 tablet by mouth twice a day for seizure starting at 8 a.m. on 10/21/25, and another for 150 mg, 1 tablet by mouth every 12 hours for seizures starting at 9 p.m. on 10/21/25. The MAR showed one lacosamide order scheduled at 8 a.m. and 5 p.m. and another scheduled at 9 a.m. and 9 p.m. The controlled drug record indicated lacosamide 150 mg was correctly given twice daily from 10/11/25 to 10/16/25, but on 10/21/25 it was given once, on 10/22/25 it was given three times, and on 10/23/25 it was given four times at 8 a.m., 9 a.m., 5 p.m., and 9 p.m. Progress notes on 10/23/25 documented that at 6 p.m. the resident complained of dizziness, evening medications were given at 8 p.m., and at 9 p.m. the resident again complained of dizziness and requested transfer to the hospital; 911 was called and the resident was transported. The DON confirmed the multiple lacosamide administrations on those dates. LVNs involved stated they did not remember giving lacosamide twice on the same shift and indicated they followed what was in the MAR. The consultant pharmacist stated the maximum daily dose of lacosamide is 400 mg and that the resident received 600 mg on 10/23/25, described this as an error due to failure to discontinue the first order when the second was entered, and noted that nurses could input orders without oversight. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, following the six rights of medication administration and comparing the medication source with the MAR, and to administer within 60 minutes before or after the scheduled time unless otherwise ordered.