Failure to Administer PRN Seizure Medication Due to Inaccessible Med Cart
Penalty
Summary
The deficiency involves the facility’s failure to administer an ordered PRN seizure medication when a resident experienced a seizure. The resident had a history of epilepsy and other conditions including type 2 diabetes mellitus, moderate persistent asthma, anxiety, orthostatic hypotension, and peripheral vascular disease. Her MDS indicated intact cognition with a BIMS score of 14, and she was receiving multiple scheduled anticonvulsant and seizure medications, including Divalproex Sodium, Levetiracetam, Primidone, and Topiramate, as well as a PRN order for Midazolam nasal solution to be given for seizures lasting more than two minutes. The care plan directed staff to administer medications as ordered and to observe for side effects of anticonvulsant use. On the day of the incident, the resident experienced an aura and used her call light, telling a CNA that she was about to have a seizure. The CNA ensured she was safe in bed and then went to get the nurse on duty but was unable to locate the nurse. The CNA then went to the DON’s office for help. During this time, the resident proceeded to have a seizure, which the CNA estimated lasted approximately 10 to 12 minutes. The DON later reported that when she arrived, the resident was convulsing in bed, and the DON turned her onto her side and monitored her airway, which remained clear, and the seizure lasted about five minutes by the DON’s account. Record review showed that prior to the seizure, the resident had received all scheduled seizure medications as ordered, but the PRN Midazolam was not documented as administered during the seizure. Observation of the medication cart confirmed that four doses of the PRN Midazolam were available. Staff interviews revealed that the nurse on duty had gone on break and had taken the medication cart keys, leaving no one able to access the cart and obtain the Midazolam when the seizure occurred. The DON verified that the resident did not receive the ordered PRN Midazolam during the seizure because the medication cart could not be accessed in the nurse’s absence.
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