Failure to Provide Prescribed Emergency Seizure Medication
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including epilepsy and a history of seizures, was not provided with their prescribed emergency seizure medication, Valtoco, as ordered by the physician. The resident was admitted with several diagnoses requiring anticonvulsant therapy and had a standing order for Valtoco to be administered intranasally as needed for seizures. Despite this, the medication was not available or administered during a seizure event, as documented in the medical record and confirmed by staff interviews. The medication was not reordered after a pharmacy change, and the resident did not receive the prescribed seizure medication during a documented seizure, resulting in the need for emergency medical intervention and hospitalization. The facility's records and staff interviews revealed that the medication was unavailable from the time of the pharmacy change until it was reordered and delivered over a month later. During this period, the resident experienced a seizure, and staff confirmed that the emergency medication was not on hand, leading to the resident being sent to the hospital where alternative seizure medications were administered. The facility's policy required medications to be administered as ordered, but this was not followed, resulting in a significant medication error affecting the resident.