Failure to Administer Ordered Anti-Seizure Medications and Notify Practitioner
Penalty
Summary
The deficiency involves the facility’s failure to follow its Medication Administration Policy by not ensuring timely availability and administration of a resident’s ordered anti-seizure medications and not notifying the practitioner when the medications were not available. A resident with epilepsy was discharged from the hospital with orders for three anti-seizure medications: topiramate 200 mg twice daily, phenytoin (Dilantin) 200 mg twice daily, and oxcarbazepine 1,200 mg twice daily, with the next scheduled doses due in the evening. Record review showed that none of these medications were administered that evening as directed by the hospital discharge medication list. The DON stated that due to a holiday pharmacy delivery cut-off, only phenytoin was available in the facility’s medication dispensing system, and that the nurse should have attempted to obtain medications from the dispensing system and, if not available, notify the physician and family. The DON confirmed that the nurse did not notify the nurse practitioner that two of the three anti-seizure medications were not available and that no anti-seizure medications were given that evening. The nurse practitioner reported being notified only of the resident’s admission and not of the unavailability of the anti-seizure medications or the missed evening doses, and stated he was unaware of the pharmacy’s holiday cut-off. Review of the MAR confirmed that the ordered anti-seizure medications were not administered as scheduled on the evening in question, and there was no progress note documenting notification to the practitioner about the missed doses or unavailable medications. The following morning, a progress note documented that the resident’s concerned party insisted on calling 911 because the resident had a seizure, and later documentation showed the resident was admitted to a local hospital with seizure activity. The facility’s Medication Administration Policy required that if medication is not given as ordered, the reason must be documented on the MAR and the health care provider notified, that staff should obtain medications from contingency sources if not present, and that the physician must be notified in a timely manner if an order cannot be followed, with documentation in the medical record. These policy requirements were not followed in this case.
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