F0760

D

Failure to Administer and Document Seizure Medications as Ordered

Creve Coeur, Missouri Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when ordered anticonvulsant and related medications were not administered or documented as given on multiple occasions. Facility policies required that physician orders be complete and accurately transcribed to the MAR, that medications be administered as prescribed, and that staff document administration directly after giving each dose. Policies also required that missed doses of vital medications be addressed and that seizure precautions consider missed anticonvulsant doses. Despite these policies, review of the resident’s paper MARs for February showed numerous blank administration boxes for scheduled doses of Depakote ER, levetiracetam, lacosamide, and lorazepam, with no explanatory documentation.

The resident had moderate cognitive impairment and diagnoses including seizure disorder, repeated falls, dementia, Parkinson’s disease, and stroke. The care plan identified the resident as at risk for seizures with a goal to decrease seizure frequency, and approaches included administering medications as ordered. Physician orders included multiple scheduled anticonvulsants (Depakote ER in morning and bedtime doses, levetiracetam BID, lacosamide BID) and lorazepam 1 mg every 12 hours. MAR review showed Depakote ER 1,250 mg at bedtime was not documented as given on several dates, lacosamide and levetiracetam afternoon and morning doses were not documented as given on multiple dates, and lorazepam 1 mg scheduled every 12 hours was not documented as given for numerous morning and evening doses. A handwritten PRN lorazepam order and stat/PRN lorazepam orders from hospice on one date were partially documented with times but often without nurse initials, and there was no corresponding progress note describing seizure activity around the time those PRN orders were used.

Staff interviews further described actions and inactions contributing to the deficiency. One LPN acknowledged documenting in a progress note that lorazepam had been given based on looking at a controlled substance count sheet, while admitting that some days nurses were not signing the paper MARs because it was “too much” work after CMTs were removed from passing certain medications. This LPN stated there were days when morning medications were not passed until after lunch and admitted not checking whether the resident’s other anti-seizure medications were being given as ordered because they could not keep up. A CMT reported working on a day when none of the resident’s medications were signed out on the day shift MAR and suggested the resident’s MARs might not have been in the binder, adding that some residents did not have MARs and the CMT did not know who they were or to whom this was reported. Another LPN reported witnessing the resident have multiple seizures in the dining room on one morning but did not write a progress note, stating the resident often had seizures. The hospice RN and the resident’s physician both reported increased seizure activity that month, and the physician specifically attributed the change to missed seizure medications at the facility and noted the resident had previously had an immediate seizure episode after missing just one dose of seizure medication.