F0580

D

Failure to Notify Physician and Responsible Party of Missed Seizure Medications, Overdose, and Hospital Transfer

Salyersville, Kentucky Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify a resident’s physician and responsible party (RP) when required, in connection with missed and incorrect doses of an anti-seizure medication and a subsequent transfer to the hospital. The facility’s Medication Error Standard of Practice, dated 04/2025, required that upon a suspected or identified medication administration error, the administering nurse or medication aide immediately alert the DON and/or charge nurse for physician notification. The resident, admitted on 01/29/2026 with diagnoses including acute and chronic respiratory failure with hypoxia, anoxic brain damage, severe intellectual disabilities, and a seizure disorder, had a physician order for Vimpat 100 mg twice daily and Zonisamide 200 mg daily. Review of the MAR showed that Vimpat was documented as not available and not administered for multiple consecutive doses from 01/29/2026 through the morning dose on 02/01/2026, with no evidence that the physician was notified that the ordered anti-seizure medication was unavailable and not being given.

On 02/01/2026, the resident received an incorrect dose of Vimpat. A Medication Variance Form dated 02/02/2026 and the facility’s investigation indicated that LPN1 administered 200 mg of Vimpat instead of the ordered 100 mg. A late entry progress note, the investigation, and a hospital report dated 02/02/2026 documented that the resident was transferred to the hospital for evaluation of a medication overdose after a significant change in condition. The Medication Variance Form reflected that the physician was notified of the error on 02/01/2026 with no new orders and that the RP was notified on 02/02/2026. However, interviews with the medical director and PA1 established that they were not informed of the missed anti-seizure doses from 01/29/2026 through 02/01/2026, and PA1 stated she was not immediately informed of the medication error that occurred around 6:00 PM on 02/01/2026, only learning of concerns later that night when called about the resident’s low oxygen level, drowsiness, and increased secretions.

Interviews also showed discrepancies between documented notifications and what actually occurred. The RP reported that she first learned of the situation from the hospital, which called her at 1:56 AM to report that the resident had been sent there for a medication error; she stated no one from the facility had notified her of the transfer, the missed medications, or the overdose. LPN1 told surveyors she was unaware of the medication error until she was called on 02/02/2026 to complete a report, despite having documented physician and RP notification on 02/01/2026. Other staff interviews contradicted LPN1’s account: LPN2 stated that during shift change at 7:00 PM on 02/01/2026, LPN1 realized she had given the wrong dose, and the weekend supervisor stated that at the end of his 7:00 AM–7:00 PM shift on 02/01/2026, LPN1 informed him of the medication error. Both LPN2 and the weekend supervisor indicated they expected LPN1 to notify the provider and RP, but the supervisor did not follow up to ensure this occurred. The DON stated it was her expectation that any nurse who identified a medication error would immediately notify the physician and responsible party.