F0760

D

Late Administration of Anti-Seizure Medications by Agency Nurse

Pinehurst, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when scheduled anti-seizure medications were not administered as ordered. Resident #12, admitted with intractable epilepsy without status epilepticus and with moderately impaired cognition, had active physician orders for Lacosamide 150 mg twice daily via G-tube, Levetiracetam 1000 mg every morning and at bedtime via G-tube, and Phenytoin Sodium Extended 100 mg twice daily via G-tube. The resident’s care plan included an intervention to give anti-seizure medications as ordered by the physician. The March 2026 MAR showed that Phenytoin Sodium Extended 200 mg was scheduled for 8:00 AM, Lacosamide 150 mg for 9:00 AM and 5:00 PM, and Levetiracetam 1000 mg for 9:00 AM and 9:00 PM.

On 3/16/26, Nurse #2, an agency nurse who worked intermittently at the facility, did not administer the resident’s scheduled 8:00 AM and 9:00 AM anti-seizure medications until 12:07 PM, resulting in the medications being given 3 to 4 hours late and outside the facility’s acceptable one-hour before/after administration window. In an interview, Nurse #2 stated he fell behind on morning medication administration and did not request assistance to ensure medications were given on time. The DON stated that seizure medications were required to be administered on time, that agency staff had been instructed to request help if they fell behind, and that she was unaware the medications had been given outside the acceptable timeframe. The Medical Director confirmed the late administration of the anti-seizure medications and noted that, although the resident did not appear to have suffered ill effects and vital signs remained within normal limits with no documented seizure activity, the delay could have increased the resident’s risk for seizure activity.