Failure to Provide Prescribed Seizure Medications as Ordered
Summary
The facility failed to ensure that prescribed seizure medications, Lacosamide (Vimpat) and Clobazam, were available and administered as ordered for a patient diagnosed with epilepsy. Multiple instances were documented where these medications were not available in the facility, as evidenced by medication administration records (MAR), controlled drug records (CDR), and nursing progress notes. Specific dates were noted where the medications were not present, and nurses documented the unavailability in the patient's records, with no signatures on the CDR to indicate administration. Interviews with the patient confirmed that there were multiple days when the prescribed medications were not received. Nursing staff also acknowledged that there were times when the medications were not available, and one nurse admitted to incorrectly documenting that a medication was given when it was not, due to its unavailability. The Director of Nursing confirmed the absence of the medications on the specified dates and acknowledged that the medications were not present in the facility to be administered as prescribed. A review of facility policies indicated that there should be a systematic approach to ensure timely acquisition and administration of medications, but these procedures were not followed in this case. The failure to provide the necessary medications as ordered was substantiated by direct observation, interviews, and record reviews, demonstrating a breakdown in the facility's pharmaceutical service requirements.
Plan Of Correction
C1930: T22 DIV5 CH3 ART3- 72355(a)(1)(D) Pharmaceutical Service - Requirements Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, DON ensured the Lacosamide and Clobazam was available for use for Patient 8. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD performed an audit of all patients on seizure medications to ensure that the medications were available for use in the medication carts. There were no other issues identified. (To continue page 17 of 25) Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nursing staff regarding prompt ordering of medications and strategies for follow-up with pharmacy and physician to ensure prompt delivery. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will perform an audit of all patients on seizure medications to ensure that the medications are available for use in medication carts. These audits will continue weekly for 1 month. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Penalty
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