F0842

D

False Documentation of Anticonvulsant Administration

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

Penalty

Fine: $85,666

Summary

Facility staff failed to maintain accurate, resident-specific medical records when an LPN falsely documented administration of an anticonvulsant medication. A resident with diagnoses including convulsions, hypertension, and spastic hemiplegia had a physician’s order for Lacosamide 200 mg by mouth twice daily for seizure precaution. A quarterly MDS showed the resident had intact cognition (BIMS score 15), no rejection of care behaviors, an active diagnosis of epilepsy with status epilepticus, and receipt of anticonvulsant medications. The controlled drug receipt/record/disposition form for Lacosamide indicated that the last available dose was administered on 06/06/25 at 10 PM by the LPN, with a documented count of zero tablets remaining.

Despite the controlled drug record showing no remaining tablets after 06/06/25, the June 2025 MAR showed that the same LPN documented administration of Lacosamide 200 mg to the resident on 06/07/25, 06/09/25, and 06/11/25 at 10 PM. Review of the Omnicell inventory for June 2025 showed six Lacosamide 200 mg tablets in stock and available in the facility, but there was no documented evidence that any Lacosamide tablets were removed from the Omnicell or delivered from the pharmacy corresponding to the doses charted on those dates. A facility-reported incident stated that, upon review of the controlled drug disposition form, the resident had not received the medication on the dates for which the LPN had signed the MAR, demonstrating that the LPN falsely documented administration of the Lacosamide doses.