F0760

D

Failure to Administer Anti-Seizure Medication per Ordered Dose

Bay Shore, New York Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident was free from significant medication errors when staff did not administer Vimpat (lacosamide) in accordance with physician orders and the facility’s medication administration policy. The resident, admitted with cerebellar stroke syndrome, conversion disorder with seizures or convulsions, and depression, had a hospital discharge order and subsequent physician order for Vimpat 50 mg by mouth twice daily. The facility’s policy required staff to verify a physician’s order, check the medication label against the MAR, and confirm the medication name and dose prior to administration. Despite this, an e-script order was entered for Vimpat 200 mg twice daily, which the pharmacy filled and delivered as 200 mg tablets. The electronic MAR, however, continued to reflect an active order for Vimpat 50 mg twice daily.

Over several days, four LPNs administered Vimpat 200 mg by mouth for four doses while documenting administration of 50 mg on the MAR. The medication card for Vimpat 200 mg showed four missing tablets, and the narcotic count sheet documented four administrations of the 200 mg dose. The facility-reported incident and medication error report confirmed that the resident received 200 mg doses on multiple shifts while the MAR still listed a 50 mg dose. The DON stated that the physician had entered the incorrect 200 mg dose into a separate e-script system that is not linked to the electronic medical record for narcotics, and there was no process in place to reconcile the narcotic e-script order with the physician order in the resident’s chart. The physician confirmed the incorrect prescribing of Vimpat 200 mg instead of 50 mg, and the error was identified after four doses had been given.