Failure to Obtain and Administer Ordered Seizure Medication
Penalty
Summary
The facility failed to obtain and administer Lacosamide, an ordered seizure medication, for one resident, resulting in 11 missed doses over the period from 1/7 to 1/13. The resident was admitted with diagnoses including epilepsy, paranoid schizophrenia, and dementia. Review of the care plan showed no care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR for 1/7/26 through 1/14/26 showed that the resident did not receive Lacosamide 100 mg, ordered as 1.5 tablets by mouth twice daily for seizures, for a total of 11 missed doses. The facility’s policy on Adverse Consequences and Medication Errors defined a medication error to include omissions when a drug is ordered but not administered. During interviews, an LPN stated that if a progress note about Lacosamide not being given was scratched out, it meant the medication was administered, and that when waiting for a medication, the nurse keeps a running list and calls the pharmacy for status updates. The Staff Development Coordinator reported that the protocol for missing medications requires nurses to call the pharmacy and document the call, notify the MD for alternatives, and check the Omnicell if the medication is not a narcotic. The DON stated that on admission, floor nurses should send all prescriptions to the pharmacy and, if a prescription is missing, contact onsite/on-call providers to obtain one so the pharmacy can send the medication stat, and reported being unaware that there was no prescription for Lacosamide. The resident’s PCP stated she had no memory of being notified about any missed Lacosamide doses and explained that the NP should be notified first and work with the pharmacy, and if issues persist, the PCP should be contacted; she also stated that missing medication should be communicated immediately by direct means, not by a note left in a book.
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