Failure to Administer and Document Ordered Seizure and Sleep Medications
Penalty
Summary
The facility failed to provide ordered pharmaceutical services when one resident did not receive multiple scheduled medications on the day of admission. The resident was admitted late in the evening with diagnoses including unspecified intracranial injury, nontraumatic subarachnoid hemorrhage, epilepsy, and cerebral edema. Physician orders dated 11/29/2025 included levetiracetam 1000 mg by mouth twice daily at 9:00 a.m. and 8:00 p.m. for seizures, phenytoin 50 mg chewable tablets, 2 tablets by mouth three times a day, and trazodone 75 mg, 0.5 tablet by mouth at bedtime (9:00 p.m.) for insomnia related to depression. Review of the Medication Administration Record for 11/29/2025 showed the resident did not receive levetiracetam 1000 mg at 8:00 p.m., phenytoin 50 mg at 8:00 p.m., or trazodone 75 mg at 9:00 p.m., and there was no documentation explaining why these medications were not administered. Pharmacy records showed levetiracetam 1000 mg and trazodone 75 mg were delivered to the facility at 1:04 a.m. after the scheduled administration times, while a STAT order for phenytoin was delivered at 5:48 p.m. and received by LVN A. The Pharmacy Manager stated that the resident’s medication orders were received too late to meet the 1:00 p.m. delivery and were therefore scheduled for the 9:00 p.m. delivery, and that the facility could have requested all medications as STAT orders but only phenytoin was ordered STAT. The Nursing Supervisor, who admitted the resident and sent the medication orders to the pharmacy, stated he was aware of the 1:00 p.m. delivery time and assumed the medications would arrive by bedtime, so he ordered only phenytoin as STAT. The DON confirmed that LVN A did not administer the three night medications at their scheduled times and that phenytoin, which had been delivered at 5:48 p.m., should have been administered at 8:00 p.m. LVN A stated the resident had not received medications by bedtime and acknowledged that phenytoin, trazodone, and levetiracetam were not administered and that she did not document the reason, citing unfamiliarity with entering notes in the updated medication administration system. The facility’s policy on oral medication administration required medications to be administered in an accurate, safe, and timely manner.
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