Shady Lake Nursing Home: Medication Left Bedside - LA
LAKE PROVIDENCE, LA - Federal inspectors documented medication administration failures at Shady Lake Nursing Home after discovering critical medications left unattended on a vulnerable resident's bedside table overnight.
Critical Medication Error Discovered During Morning Rounds
During a federal inspection on May 19, 2025, surveyors found two tablets sitting in a medication cup on the bedside table of a resident with multiple serious health conditions. The resident, identified in records as Resident #55, has diagnoses including HIV disease, seizure disorder, unspecified psychosis, and monoplegia affecting a lower limb.
A Licensed Practical Nurse (LPN) at the facility confirmed to inspectors that the medications were Levetiracetam, an anti-seizure medication, and a stool softener. The nurse acknowledged these were the resident's night medications that "should have been administered the prior night."
The resident's quarterly assessment showed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This cognitive status makes proper medication administration particularly critical, as the resident may not have the capacity to self-administer medications safely or recognize when doses are missed.
Serious Health Risks from Missed Anti-Seizure Medication
Levetiracetam is an anticonvulsant medication that must be taken consistently to maintain therapeutic blood levels and prevent breakthrough seizures. When doses are skipped or delayed, patients face increased risk of seizure activity, which can lead to falls, injuries, aspiration, and status epilepticus - a life-threatening medical emergency where seizures last longer than five minutes.
For a resident with documented seizure disorder and HIV disease, missing anti-seizure medication creates compounded risks. Seizures can interfere with adherence to HIV treatment regimens and potentially affect the absorption of other critical medications. Additionally, the resident's monoplegia (paralysis of one limb) already limits mobility, making seizure-related falls particularly dangerous.
The presence of unattended medications on the bedside table also created a separate safety hazard. Residents with cognitive impairment and psychosis may not understand medication purposes or proper dosing, potentially leading to accidental overdose if medications are taken inappropriately or at wrong times.
Documentation Failures Compound Medication Error
Investigation into the facility's Medication Administration Record (MAR) revealed no documented medication refusals by Resident #55 on May 18, 2025 - the night the medications should have been given. This documentation gap indicates staff either failed to administer the medications without noting the omission, or administered them but left them at the bedside instead of ensuring the resident took them.
Standard nursing home protocols require direct observation of medication administration, particularly for residents with cognitive impairment. Staff must watch residents swallow medications and document administration immediately. Leaving medications unattended violates fundamental safety protocols designed to prevent medication errors, missed doses, and potential adverse events.
The facility's Director of Nursing was notified about the medication error on May 20, 2025, indicating a full day passed before administrative staff became aware of the safety violation discovered by inspectors.
Pattern of Care Failures for Vulnerable Resident
The medication error represents a breakdown in basic care processes for one of the facility's most vulnerable residents. With documented cognitive impairment, seizure disorder, HIV disease, psychosis, and physical limitations from monoplegia, Resident #55 requires careful medication management and close supervision.
Anti-seizure medications require strict adherence to dosing schedules. Therapeutic drug monitoring ensures blood levels remain stable to prevent seizures. When doses are missed, residents may experience breakthrough seizures within 24-48 hours, depending on the medication's half-life and their individual seizure threshold.
The federal citation noted this deficiency affected few residents with minimal harm or potential for actual harm. However, medication errors involving anti-seizure drugs for cognitively impaired residents with multiple comorbidities reflect systemic issues with medication administration protocols and staff training.
Nursing homes must maintain systems ensuring all medications are administered as prescribed, properly documented, and never left unattended where confused residents might access them inappropriately. This incident at Shady Lake Nursing Home demonstrates failures in these fundamental safety measures, potentially endangering residents who depend entirely on staff for their medication management and daily care needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shady Lake Nursing Home from 2025-05-21 including all violations, facility responses, and corrective action plans.
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