F0684

D

Failure to Implement Admission Medication Orders and Administer PRN Seizure Medication

Erie, Pennsylvania Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to transcribe and implement hospital discharge medication orders at admission for one resident and failed to follow physician orders for seizure medication administration. Facility policy stated that written transfer orders signed and dated by the current attending physician on the date of admission should be implemented without further validation, and that any unsigned or differently dated orders, or those signed by another physician, must be verified with the attending physician and documented. The resident, admitted with COPD, epilepsy, and a history of stroke, had hospital discharge instructions dated 3/26/25 that included Aspirin 81 mg by mouth every morning and Cholecalciferol (Vitamin D3) 50 mcg by mouth daily. Between admission and 1/7/26, the facility’s physician orders and MARs showed no evidence that these medications were ordered or administered, and admission progress notes lacked documentation that the resident’s physician was notified or made any changes to the hospital discharge instructions.

The same resident’s hospital discharge instructions also included Clonazepam 0.5 mg every 24 hours PRN for seizures, and the facility’s physician orders reflected this PRN seizure medication. On 12/8/25, progress notes documented that the nurse was called to the resident’s room after the resident was found on the floor, complained of headache, lightheadedness, and dizziness, and was assisted to bed and placed on a bedpan. When staff returned, the resident was observed having seizure-like activity with an approximate 13-minute seizure, followed by another seizure of about one minute. The clinical record progress notes and MAR lacked evidence that Clonazepam 0.5 mg PRN was administered during these seizure events, despite the existing physician order for PRN seizure management.