F0760

J

Missed Anti-Seizure Medication Doses Lead to ICU Admission

Saint Louis Park, Minnesota Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident with a seizure disorder consistently received a prescribed anti-seizure medication, Lacosamide 200 mg twice daily, resulting in multiple missed doses over several days. The resident had diagnoses including encephalopathy, seizure disorder, generalized weakness, alcoholic dementia, and metabolic encephalopathy, and the care plan required administration of anti-seizure medication as ordered, positioning to prevent injury during seizure activity, airway management, documentation of seizure characteristics, and monitoring of neurological status after any seizure activity. Physician orders also directed staff to monitor for seizure activity every shift.

The January Medication Administration Record showed that the resident did not receive either scheduled dose of Lacosamide on three consecutive days, with six missed doses documented as “medication not available,” and an additional morning dose was not administered on a subsequent day. Three different nurses failed to administer these doses. During this period, there was no documentation that the physician or pharmacy had been notified that the medication was unavailable or that doses were missed, despite the standing order and facility policy requiring medication ordering and reordering when supplies were low. The Treatment Administration Record showed that seizure monitoring tasks were checked off as completed, but the resident’s record and progress notes did not contain documentation of the results of this monitoring or any evidence of increased monitoring after the missed doses.

Nursing staff interviews revealed multiple failures in communication and follow-through. One LPN reported caring for the resident on two evenings, finding the medication absent from the cart, and not administering the doses; he did not notify the pharmacy, provider, or nurse manager and did not report the issue to the night nurse. Another LPN stated she received report that the anti-seizure medication was not available, called the pharmacy to reorder it, and was told it would be delivered; she observed that the medication arrived as she was leaving but did not notify the provider or give report to the night nurse, and the dose was not given. A unit manager RN later found 10 tablets of Lacosamide in the medication cart after the resident had been sent to the hospital. A pharmacist confirmed there were no electronic requests for the medication on two of the days in question and that a prescription was already on file to supply the facility upon request. A nurse practitioner reported having no record of any notification from the facility about the medication being unavailable or any refill request, and described being called only when the resident had a change in condition and was found actively seizing, with three seizures observed within seven minutes before EMS transport to the hospital ICU.

On the morning the resident was transferred to the hospital, an RN caring for the resident found the resident very sleepy and difficult to arouse and determined it was not safe to administer medications, including the anti-seizure medication, and notified the onsite provider of the change in condition. A progress note documented that the resident was non-responsive and tremoring, and the provider ordered transfer to the hospital. Hospital admission notes indicated the resident was admitted to the ICU with seizure activity and concern for status epilepticus, requiring intubation and ventilator support, and that the resident had been out of Lacosamide for the past three days because it had not been available. A head CT scan identified a thin subdural hemorrhage versus dural thickening along the left cerebral convexity. The DON stated that staff failed to obtain the medication from the pharmacy, resulting in missed doses, did not update the provider when doses were missed, and did not follow medication re-order procedures or complete follow-up to ensure timely delivery of the medication.

Removal Plan

• Suspended LPN-A, LPN-B and LPN-C pending investigation and provided re-education.
• Reviewed the policy and procedure for safe medication and developed a plan to ensure a sufficient supply of medications for residents for timely administration.
• Reassessed all residents with seizure medications to ensure their safety.
• Began re-education and competency testing for nursing staff to ensure compliance with medication administration.