Failure to Transcribe and Provide Immediate-Use Seizure Medication
Penalty
Summary
A resident with a history of seizure disorder, Lennox-Gastaut syndrome, and intellectual disabilities was admitted to the facility with a hospital discharge summary that included an order for Diazepam nasal spray as an immediate-use medication for active seizures. Upon admission, the medication reconciliation process conducted by a registered nurse and a nurse practitioner failed to transcribe the Diazepam nasal spray order into the resident's electronic medical record. As a result, the medication was not available in the facility. Subsequently, the resident experienced a prolonged seizure episode during which staff were unable to administer any oral medications due to the resident's condition. Emergency services were called, and the resident was transferred to the hospital for treatment. Interviews with the admitting nurse and nurse practitioner revealed uncertainty and lack of recall regarding the omission of the Diazepam nasal spray order during the admission process. The facility's policy required two nurses to review all medication entries, but this process did not ensure the inclusion of the necessary seizure medication.