Dilantin Administered After Order to Hold Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff administered Dilantin despite an active order to hold the medication. Facility policy required medications to be administered in accordance with written prescriber orders. The resident, admitted with a history of seizures and care planned as being at risk for complications related to seizures, had an active order for Dilantin 50 mg chewable tablets, three tablets by mouth twice daily. A quarterly MDS showed the resident had intact cognition and was receiving an anticonvulsant during the assessment period. On the day of the incident, a lab result showed the resident’s Dilantin level was greater than 40 mcg/mL. LPN #5 documented that the physician was notified and ordered the Dilantin to be held and the level repeated on a later date. Despite this order to hold the medication, the Medication Administration Audit Report showed that LPN #5 administered a dose of Dilantin to the resident later that same evening. The physician later stated concern that the resident received more Dilantin after he ordered it held, though he reported no lasting effect from the extra dose. The ADON, DON, and Administrator each confirmed through review of the electronic medical record that the nurse administered Dilantin after the order to hold the medication had been received, contrary to the physician’s order and facility policy.
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