Failure to Administer Seizure Medication Accurately and Timely
Penalty
Summary
The facility failed to ensure accurate and timely administration of a prescribed seizure medication for one resident. The resident had diagnoses including other seizures, neuromuscular bladder dysfunction, and multiple muscle contractures, and had a BIMS score indicating severe cognitive impairment. The resident had a physician’s order for Valproic Acid oral solution, 15 ml via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. Review of the MAR showed that on 9/15 the morning dose was documented as given by a nurse, and the evening dose was documented as given by another nurse. However, the facility’s Medication Admin Audit Report revealed that the 7:30 AM dose was actually administered and documented at 12:44 PM, well outside the one-hour before/after window described by the DON, and there was no record on the audit report that the 9:00 PM dose was administered at all. A complaint to the State Agency alleged that on that date the nurse falsified having given the resident their needed seizure medication, resulting in the resident sustaining two seizures during the night, and further alleged that this nurse often provided medications late or not at all. Nursing notes from the early morning of the following day documented that the resident experienced an active seizure at 4:23 AM and a second seizure at 4:23 AM lasting until 4:25 AM, with the resident positioned on the left side and suction available and the physician contacted. During interview, the DON confirmed that the Valproic Acid dose scheduled for 7:30 AM but administered at 12:44 PM was significantly delayed and that, after reviewing the audit, the 9:00 PM dose had not been administered. The facility’s Medication Errors policy stated that medications are to be administered according to physician orders and that time of administration and medication omission are factors indicating errors in medication administration.
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