Failure to Timely Refill and Properly Administer Anti-Seizure Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure anti-seizure medications were refilled in a timely manner and administered from the correct resident-specific supply, in accordance with professional standards and facility policy. Resident #1 had diagnoses including epilepsy, multiple sclerosis, repeated falls, and adjustment disorder, and had physician orders for levetiracetam 1000 mg twice daily and oxcarbazepine 300 mg twice daily for seizure control. The resident’s care plan identified seizure risk and included interventions to medicate as ordered and monitor for effectiveness and side effects. An SBAR note documented that on 11/10/25 the resident experienced a seizure, the provider was notified, Ativan 1 mg IM was ordered as a rescue medication, and the resident was transferred to the ED for further evaluation. Review of the October and November Medication Administration Records showed all scheduled doses of levetiracetam and oxcarbazepine at 9:00 AM and 9:00 PM were signed as administered, and a nurse’s note by the former DON stated there were no missed doses. However, pharmacy records and order audit reports showed repeated delays in reordering both medications, with multiple refills requested several days to two weeks after the prior 14‑day supply should have been exhausted. The pharmacist confirmed that both medications were dispensed in 14‑day supplies, that no STAT deliveries were requested for these drugs during the review period, and that levetiracetam was available in the Pyxis emergency supply while oxcarbazepine was not. A Pyxis report showed that levetiracetam had not been pulled from emergency stock for this resident during the relevant timeframe. Multiple nursing staff interviews revealed that when the resident’s levetiracetam and oxcarbazepine could not be located, nurses did not follow facility procedures for medication unavailability. A 3–11 PM RN reported that when she returned after days off, she frequently had to refill the resident’s anti-seizure medications and, if they were not available, she would obtain doses from other residents who were on the same medications rather than notify the supervisor, pull from Pyxis, or call the pharmacy for a STAT refill. Several LPNs similarly reported that when they could not find the medications on several occasions, they took doses from other residents’ anti-seizure medication supplies instead of contacting the supervisor, using Pyxis, or arranging refills through the pharmacy or eMAR. The DON confirmed that the medications had not been pulled from emergency stock for this resident, that charge nurses were responsible for reordering when two to three days of supply remained, and that nurses should not use other residents’ medications at any time. Facility policies on reordering medications and medication administration required timely communication with the pharmacy and adherence to the seven rights of medication administration, which were not followed in these instances.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.