F0684

G

Failure to Administer Ordered Anticonvulsant Leading to Multiple Seizures and Hospitalization

Washington, District Of Columbia Survey Completed on 03-03-2026

Penalty

Fine: $85,666

Summary

Facility staff failed to provide ordered anticonvulsant medication to a resident with a convulsion disorder, resulting in missed doses over several days. The resident had a history of convulsions related to head injury, hypertension, and spastic hemiplegia, with an active diagnosis of epilepsy and an order for Lacosamide 200 mg orally twice daily for seizure precautions. The resident’s care plan required seizure medication to be given as ordered and monitored for effectiveness and side effects. The controlled drug record showed the last available dose of Lacosamide was administered on 06/06/25 at 10 PM, with a count of zero tablets remaining, and the facility’s policy required refills to be ordered at least three days before the last dose.

From 06/07/25 through 06/12/25, the Medication Administration Record (MAR) documented that multiple scheduled doses of Lacosamide were not administered, with entries of “5=Hold/See Progress Notes” and “9=Other/See Progress Notes” at several administration times. Despite this, an LPN documented check marks and initials on the MAR indicating that Lacosamide was administered on three evenings, even though there was no evidence that the medication had been removed from the Omnicell or delivered from the pharmacy, and the controlled drug disposition form showed no doses available after 06/06/25. Pharmacy records confirmed that no additional doses had been ordered or delivered after that date, and a prescription written on 06/06/25 was not faxed to the pharmacy until 06/12/25.

During the period when doses were missed, the resident experienced changes in condition and seizure activity. On 06/09/25, security staff reported that the resident was not responding as usual, and the resident was assessed with the MD made aware but no new orders given. On 06/11/25, the resident had a seizure after smoking, with tongue biting and bleeding, and was transported to the hospital. The resident returned later that day, and on 06/12/25, nursing documentation noted that the resident did not have Lacosamide 200 mg available. That same morning, the resident had another tonic-clonic seizure, followed by another seizure and an episode of coffee-brown emesis, leading to a rapid response and transfer to the hospital. The resident was later discharged from the hospital after treatment for seizures and bacteremia. The facility’s review concluded that the resident missed a total of 10 doses of Lacosamide, that staff did not timely fax the prescription, did not administer available doses from the Omnicell, and did not notify the physician that multiple doses had been missed.