F0760

J

Failure to Administer Ordered Antiepileptic Medications and Notify Providers of Missed Doses

Fort Collins, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident with epilepsy and acute kidney failure requiring hemodialysis received prescribed anti-seizure medications as ordered, resulting in significant medication errors. The resident was cognitively intact but dependent on staff for all activities of daily living and had a care plan intervention to receive seizure medications as ordered and be monitored for effectiveness. The resident’s complex seizure regimen included scheduled phenobarbital, lacosamide, clobazam, and Depakote, with later addition of Tegretol, as well as PRN phenobarbital and lacosamide to be given after dialysis for breakthrough seizures. Despite these orders, the MAR and record review showed multiple missed doses of scheduled seizure medications and no administration of PRN seizure medications after dialysis, even though the resident continued to have seizures after dialysis.

Record review showed that on multiple days the resident did not receive ordered doses of lacosamide, Depakote, clobazam, and phenobarbital, including entire mornings when all four scheduled seizure medications were not administered, and additional missed evening and noon doses on other days. The MAR also showed that the PRN phenobarbital and PRN lacosamide ordered to be given after dialysis for seizures were never administered, despite ongoing post-dialysis seizure activity. After a hospitalization for seizures where subtherapeutic phenobarbital and valproic acid levels were documented, the resident returned with an order to start Tegretol three times daily; however, four Tegretol doses were not given because nurses were unaware the medication was available and stored in a separate area. Subsequent MAR review after this hospitalization showed further missed Tegretol doses on multiple days.

The facility’s practice contributed directly to these omissions. The DON stated it was facility practice to hold medications when a resident was at dialysis, and seizure medications and other medications scheduled on dialysis days were marked as not administered in the EMR without clarifying these orders with the PCP or neurologist. The DON also acknowledged awareness that four Tegretol doses were not administered but did not complete a full audit of the resident’s seizure medications and was not aware of additional missed doses beyond dialysis days. The DON and PCP both believed the PRN post-dialysis seizure medications were to be administered by the dialysis clinic, but the dialysis triage nurse and nephrologist reported the clinic did not administer medications from the facility’s orders and expected such medications to be given at the facility before or after dialysis. Throughout these events, the resident’s EMR did not contain documentation that the neurologist or PCP were notified of the multiple missed doses of anti-seizure medications. The resident experienced repeated seizures and multiple hospitalizations, with hospital records repeatedly referencing breakthrough seizures, subtherapeutic antiepileptic levels, and seizure activity despite reported adherence, while facility records showed that ordered antiepileptic medications were not consistently administered.

In addition to the issues with this resident, an observation of another medication pass showed a nurse unable to locate a prescribed inhaler for another resident and not administering it, without notifying the physician or documenting the missed dose. This further demonstrated that medications were not consistently administered as ordered and that missed doses were not reliably communicated to providers or documented in progress notes, contributing to the identified deficiency of significant medication errors.

Removal Plan

• The DON and ADON completed an audit to ensure all residents are getting medications as ordered, including a review of each resident's medication administration record and an audit of the medication carts to ensure the medications were available.
• The DON and regional clinical resource #1 audited all residents currently on dialysis to ensure administration of medications per physician order on dialysis days.
• The Medication Administration policies were reviewed by the NHA, the DON, and regional clinical resource #1.
• The DON educated all licensed nursing staff on the Medication Administration policy, properly following physician's orders, and the process of notifying of medication errors, including notifying providers when medications conflict with scheduled dialysis days; education to be provided to all nursing staff prior to their next scheduled shift.
• The DON or designee will educate all new hire licensed nurses on medication administration and physician notification guidelines during orientation.
• The DON or designee will review MAR reports for all residents to ensure medications are administered as ordered, or the physician was notified appropriately if a medication was held.
• All licensed nurses will be observed by the DON or designee administering medications to ensure competency across shifts and with various staff members.