Failure to Consistently Administer and Document Anti-Seizure Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to prescribed anti-seizure medications. The resident, admitted with multiple diagnoses including spastic hemiplegic cerebral palsy, cerebral infarction with left-sided hemiplegia, Lennox-Gastaut syndrome, other seizures, atherosclerotic heart disease, and type 2 diabetes mellitus, was cognitively intact and ambulatory with a walker. During an interview, the resident reported that doses of her anti-seizure medications (phenobarbital, Keppra, and pregabalin/Lyrica) were missed because the medications were not available or the facility was “out of it,” and that she experienced seizure episodes when she did not receive these medications. She stated she had a seizure episode a couple of weeks prior that she associated with missed doses of Keppra, phenobarbital, and Lyrica. Staff interviews corroborated that the resident had a recent seizure episode. A CNA who regularly worked on the unit and was assigned to the resident reported observing a seizure 2–3 weeks earlier in the dining room, describing shaking while the resident was in her wheelchair and noting that it was a quick seizure and did not result in hospitalization. An LPN assigned to the resident stated he follows physician orders and the “5 rights” of medication administration and that he signs or initials the MAR after giving medications, acknowledging that if the MAR is not signed or initialed, it could mean the medication was not given. The DON similarly stated that nurses are expected to sign or initial the MAR after administering medications and that if the MAR is not signed, it could possibly mean the medication was not given, adding that standard nursing practice is that if it is not documented, it was not given. Record review showed multiple missing signatures/initials on the MAR for the resident’s anti-seizure medications, indicating doses were not administered as ordered. The physician orders included pregabalin 200 mg PO twice daily at 9 AM and 5 PM, phenobarbital 100 mg PO twice daily at 9 AM and 5 PM, and Keppra 1000 mg PO twice daily at 6 AM and 6 PM. The March MAR showed no signatures/initials for Keppra on three dates and for phenobarbital and pregabalin on one date, while the February MAR showed no signatures/initials for Keppra on two dates and for phenobarbital and pregabalin on one date. A nursing progress note documented a seizure on a prior date with jerking movements of all extremities lasting one minute. The resident’s care plan identified risk for seizure activity related to Lennox-Gastaut syndrome and directed staff to administer medications as ordered. Facility policies required medications to be administered as prescribed, documented on the MAR at the time of administration, and signed out as soon as given, with refusals and reasons documented, which was not consistently done in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.