Failure to Clarify Rescue Seizure Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders were properly clarified for a resident with multiple complex diagnoses, including spastic quadriplegic cerebral palsy, seizure disorder, and congenital hydrocephalus. Record review revealed that the resident had two physician orders for rescue seizure medications—Nayzilam (midazolam) and Valtoco (diazepam)—with overlapping but not clearly differentiated instructions regarding when each should be administered. The orders did not specify which medication to use under specific seizure circumstances, leading to unclear direction for staff. During staff interview, the Acting DON confirmed that the directions for administering these medications were not clear and required clarification to prevent medication errors or overmedication.