Failure to Provide and Correctly Administer Ordered Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the anti-seizure medication Vimpat. The resident was admitted with acute and chronic respiratory failure with hypoxia, anoxic brain damage, severe intellectual disabilities, and a seizure disorder, and had an order for Vimpat 100 mg twice daily along with Zonisamide 200 mg daily. From the date of admission through several subsequent days, the Medication Administration Record showed that Vimpat was repeatedly marked as not available and was not administered for multiple scheduled morning and evening doses. There was no evidence that the facility notified the physician that this ordered anti-seizure medication was unavailable and not being given during this period. When the weekend supervisor obtained a stat delivery of Vimpat from the pharmacy, the first available dose was administered in the evening. At that time, the nurse administering medications gave 200 mg of Vimpat instead of the ordered 100 mg dose. Documentation and interviews revealed that the nurse pulled a 200 mg Vimpat tablet from another resident’s supply and administered it, resulting in the resident receiving twice the prescribed dose. The facility’s own Medication Administration and Medication Error policies required medications to be administered in accordance with orders and required immediate notification of the DON and/or charge nurse, physician notification, resident assessment, and completion of a Medication Variance Form when a medication error was suspected or identified. Interviews and records showed discrepancies in staff accounts of when the error was recognized, but confirmed that staff were aware of the error on the same evening it occurred. The resident subsequently became lethargic, with increased mucous and an increased need for suctioning, and respiratory staff noted oxygen saturation levels of 88%–92%. A late entry nursing note documented that the resident was not herself and appeared almost sedated after receiving the 200 mg dose. The on-call provider was contacted about the resident’s drowsiness, increased secretions, and difficulty maintaining oxygen levels, and the resident was sent to the emergency department, where the visit was documented as related to an overdose of antiseizure medication before the resident was returned to the facility with no new orders.
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