Failure to Provide Ordered PRN Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication needs were met by not having a physician-ordered PRN Diazepam nasal spray available for administration in the event of prolonged seizure activity. The medication was not present in the medication cart when needed because the pharmacy was waiting for the resident's medical provider to complete and return pre-authorization paperwork. Despite the order being active in the resident's electronic medical record, the medication was never received by the facility. Additionally, the resident's PRN Ativan order, which previously included seizure disorder as an indication, was discontinued and replaced with an order for anxiety only, leaving the resident without an appropriate PRN medication for seizures. Interviews with staff confirmed that the PRN Diazepam nasal spray was not available and that the Ativan order was incorrectly transcribed, omitting seizure disorder as an indication. The Director of Nursing acknowledged that since the change in the Ativan order, the resident had no medication available to treat a prolonged seizure. The facility's policies required timely acquisition and clarification of medication orders, but these were not followed, resulting in the resident being left without necessary seizure medication.