F0760

D

Crushing of Anticonvulsant Medications Contrary to Orders and Manufacturer Directions

Marshville, North Carolina Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple anticonvulsant medications ordered to be given whole were crushed and administered. The resident, who had diagnoses including cerebral infarction, epilepsy, slurred speech, and dysphagia, was cognitively intact and did not exhibit behavioral symptoms or rejection of care per a recent MDS. Physician orders specified that Brivaracetam 100 mg, Eslicarbazepine 800 mg, Lamotrigine 200 mg, and Xcopri 150 mg were to be administered orally and not crushed, with Brivaracetam explicitly ordered as “DO NOT CRUSH.” Manufacturer prescribing information for Brivaracetam and extended-release Lamotrigine stated that tablets should be swallowed whole and not chewed or crushed, while Eslicarbazepine and Xcopri could be administered whole.

On the evening in question, an agency nurse (Nurse #3), working her first shift at the facility and first time with the resident, crushed and administered the resident’s nighttime doses of Brivaracetam, Eslicarbazepine, Lamotrigine, and Xcopri. The MAR reflected that the medications were given but did not specify whole versus crushed administration. According to the resident’s POA, she was present and informed Nurse #3 that the medications should not be crushed based on the physician’s orders she had in her possession. Nurse #3 responded that the medications had already been crushed and told the resident that if she did not take them, she would not receive them again until the next night. The resident reported that Nurse #3 told her the crushed medications would not hurt her, and she took them because they were important for seizure control and she was told she would otherwise miss the dose.

Following administration of the crushed medications, the resident and her POA reported onset of symptoms including nausea, increased slurred speech beyond baseline, sweating, feeling extremely hot, and weakness within approximately 40 minutes to an hour. The POA stated she notified Nurse #3 of these symptoms and that Nurse #3 checked on the resident once during the night to obtain vital signs. NA #2, who cared for the resident that evening, reported the resident said she was scared when her medications were crushed and was noted to be sweating more than usual around the time of administration; NA #2 assisted with comfort measures but did not obtain vital signs. The pharmacist, NP, and facility physician each confirmed that crushing and administering these anticonvulsants together could alter their intended release and contribute to the symptoms described, and the NP stated the side effects the resident experienced were a direct result of the medications being crushed and administered all at once. Nursing staff did not notify the NP or physician at the time of the medication error, and the physician later reported he had been unaware of the incident.