Resident #114 was prescribed Lacosamide, an anti-seizure medication, to be taken twice daily starting December 12. Federal inspectors found the resident received no doses from December 12 through December 17, missing both morning and evening medications each day.
The facility's own medication records show a pattern of failed communication and delayed action. On December 12 at 5:59 PM, staff noted the medication was "awaiting supply on order." The next day brought identical entries: "on order. Physician aware. No seizure activity noted."
Day after day, the documentation remained virtually unchanged.
December 14: "On order. Physician aware. No seizure activity noted."
December 15: "On order pending physician to call prescription."
December 16: "Med on order."
December 17: "Prescription faxed to physician again."
Only on December 17 afternoon — five days after the medication was ordered — did Resident #114 finally receive his first dose.
RN C told inspectors the resident had been admitted on a Friday, and when she cared for him Saturday, she discovered no signed prescription for the Lacosamide. She sent a request to the physician group but received no weekend response.
The nurse tried again Monday, December 15. The physician signed the prescription, but the pharmacy rejected the signature format. At that point, Unit Manager Q took over responsibility for obtaining the proper prescription.
Unit Manager Q scanned and sent the request Monday. The physician didn't provide the signed prescription until Tuesday, but the unit manager was off that day, further delaying the process.
The inspection report reveals a cascade of communication breakdowns. Staff repeatedly documented that the physician was "aware" and noted "no seizure activity," but took no apparent action to expedite the medication supply when standard channels failed.
For someone requiring anti-seizure medication, missing doses can be dangerous. Lacosamide is prescribed to prevent seizures, and sudden discontinuation or missed doses can increase seizure risk. The facility's own documentation shows staff were tracking the resident's condition, repeatedly noting the absence of seizure activity while the medication remained unavailable.
The resident admitted on December 12 waited until December 17 for his first dose — a five-day gap that occurred not because of a medical decision, but because of administrative and communication failures between the facility, physician, and pharmacy.
Federal inspectors cited the facility for failing to ensure residents receive prescribed medications as ordered. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The case illustrates how routine administrative processes can leave residents vulnerable when systems break down. While staff documented their awareness of the missing medication and the resident's condition, the repeated "on order" entries suggest a passive approach to resolving the supply problem.
RN C's account reveals the weekend gap in physician communication, while Unit Manager Q's absence on the crucial Tuesday when the prescription finally arrived shows how staffing schedules can compound medication delays.
The facility's medication administration record became a daily chronicle of inaction: ten missed doses, ten documentation entries explaining why the medication wasn't given, but no evidence of escalated efforts to resolve the supply chain failure.
Resident #114's experience demonstrates how quickly routine medication management can deteriorate when multiple systems fail simultaneously. A Friday admission became a five-day medication gap because weekend physician coverage, pharmacy signature requirements, and staff scheduling all created obstacles that the facility failed to overcome promptly.
The inspection occurred December 23, six days after the resident finally received his medication. By then, the crisis had passed, but the documentation trail remained as evidence of a system that prioritized explaining delays over preventing them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Three Rivers from 2025-12-23 including all violations, facility responses, and corrective action plans.