Failure to Notify Supervisor When Anticonvulsant Medication Was Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff followed policy to notify the supervisor when a prescribed anticonvulsant medication was not available for administration. A resident with diagnoses including epilepsy, anoxic brain injury, and a meningioma had a care plan directing that seizure medications be given as ordered, seizure precautions maintained, and seizure activity monitored. A physician’s order required Brivaracetam 100 mg by mouth twice daily for seizures, and the controlled substance disposition record showed that tablets were on hand earlier in the day. On the evening in question, the 3–11 PM charge nurse could not locate the resident’s scheduled 8:30 PM dose of Brivaracetam in the medication cart and documented in a nurse’s note that the medication was not available. However, the nurse’s note did not reflect that the nursing supervisor, provider, or pharmacy were contacted about the missing dose, despite facility policy requiring the charge nurse to notify the supervisor when a medication is unavailable so that the supervisor can contact the provider and pharmacy. The LPN later acknowledged that although she spoke with the supervisor during the shift about another issue, she did not inform the supervisor that the Brivaracetam dose was missed. Subsequently, the resident experienced seizure activity lasting two minutes, after which the provider was notified and the resident was evaluated via telemedicine and remained at the facility. Later that morning, the resident developed sudden right extremity paralysis and was transferred to the hospital, where the event was assessed as a breakthrough seizure. Clinical record review by supervisory nursing staff and the DON confirmed that the nurse’s documentation from the prior evening did not show required notifications to the supervisor or provider when the Brivaracetam dose was unavailable, and that this omission was contrary to the facility’s Medication Pass Policy and Unavailable Medication Policy, which direct that medications be administered safely and timely per physician order and that unavailable medications prompt immediate notification of pharmacy and appropriate practitioners.
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