The error at ODD FELLOW-REBEKAH HOME involved Keppra, a critical medication used to prevent seizures in epileptic patients. Federal inspectors discovered the mistake during a November complaint investigation.
The resident's neurologist ordered two tablets of Keppra 250 milligrams twice daily on September 22, for a total daily dose of 1,000 milligrams. But nursing staff never updated the facility's medication records to reflect the increased dosage.
Instead, the resident continued receiving just one 250-milligram tablet twice daily — exactly half the prescribed amount.
Licensed Practical Nurse V3 administered the incorrect dose on the morning of November 25 during her medication pass. When inspectors questioned her about the dosage, she confirmed she was following the facility's Medication Administration Record, which showed one tablet of Keppra 250 mg twice daily.
The confusion deepened when inspectors examined the medication itself. The pharmacy had supplied 500-milligram tablets with "1/2 tab" handwritten on the bubble pack. V3 explained this meant she was supposed to give half a tablet at each dose, equaling 250 milligrams twice daily.
But the neurologist's September order clearly specified two 250-milligram tablets twice daily, not one half-tablet of the 500-milligram formulation.
Director of Nursing V2 confirmed the error when confronted by inspectors. She acknowledged that the most recent physician order called for 500 milligrams twice daily, not the 250 milligrams the resident had been receiving since September 1.
The problem stemmed from a breakdown in the facility's order transcription process. V2 told inspectors that the neurologist's facsimile order lacked a signature from facility nursing staff. The document had been uploaded into the resident's electronic medical record, but nurses never transcribed the new dosage onto the facility's Physician Order Sheet.
This meant the resident's official medication record remained unchanged despite the doctor's clear instruction to double the dose.
The resident had been receiving the incorrect dosage for nearly three months when inspectors discovered the error. Medication Administration Records showed the 250-milligram dose had been given consistently from September 1 through the morning of November 25.
For patients with epilepsy, maintaining proper anti-seizure medication levels is critical. Underdosing can lead to breakthrough seizures, which can cause injury, brain damage, or death.
The facility's medication management system failed at multiple points. The neurologist's order was received but not properly processed. Staff continued administering an outdated dosage without recognizing the discrepancy between the doctor's instructions and their own records.
Even the pharmacy packaging created additional confusion. While the 500-milligram tablets were marked for half-tablet dosing, this arrangement contradicted the neurologist's specific order for two separate 250-milligram tablets.
V2 confirmed to inspectors that nursing staff should have been administering 500 milligrams twice daily based on the neurologist's September order. The error represented a significant medication mistake that could have endangered the resident's health and safety.
The facility's failure to ensure accurate medication administration violated federal regulations requiring nursing homes to keep residents free from significant medication errors.
Inspectors found this was not an isolated incident of poor medication management, but rather a systemic failure in the facility's order transcription and verification processes.
The resident with epilepsy continued receiving inadequate seizure medication while facility staff remained unaware of their error for months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Odd Fellow-rebekah Home from 2025-11-26 including all violations, facility responses, and corrective action plans.