Failure to Follow Physician Orders for Antiseizure Medication Administration
Penalty
Summary
The facility failed to ensure physician orders for medications were followed for a resident with a seizure disorder and a lumbar vertebral fracture. The resident’s care plan dated 01/14/2026 documented a seizure disorder with a goal for the resident to remain injury free from seizure activity. During an interview on 03/02/2026 at 9:30 AM, the resident reported that their antiseizure medications were late several times and that some nurses understood the importance of these medications while others did not. The resident stated they had spoken with an LPN (Staff M) about these concerns. In a separate interview on 03/02/2026 at 10:31 AM, Staff M stated they had met with the resident and discussed concerns about antiseizure medications being given at the same time rather than spaced apart as prescribed, and identified that an agency RN (Staff N) had administered the antiseizure medications at the same time. A grievance dated 01/29/2026, signed by the resident, documented that on 01/27/2026 the nurse was an hour late giving evening medications, administered evening and bedtime antiseizure medications together at 10 PM, and did not provide the resident’s pain medication. Review of the Medication Administration Audit Report from 01/31/2026 through 02/05/2026 showed that Staff N administered the resident’s Divalproex Sodium DR tablet, scheduled for 9:00 AM on 02/01/2026, at 12:29 PM, nearly three and a half hours late.
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