IDPH has cited and fined Gilman Healthcare Center nursing home after a resident there did not receive his required anti-seizure medications, resulting in the resident experiencing multiple seizures.
The resident at issue was admitted to the nursing home on a Friday with orders which included the administration of two anti-seizure medications (Onfi and Vimpat) two times daily. The two medications were not kept on hand at the facility and had to be obtained through the nursing home’s pharmacy. In order to get those medications, the nursing home needed a hard copy of the prescriptions from the doctor who ordered the medications at the hospital. The hard copy prescription did not arrive at the nursing home with the resident, however.
Faced with this situation, the nurse who admitted the resident did not call the hospital to have the hospital send over the hard copies of the prescriptions. Instead, she faxed a request over to the attending doctor at the nursing home, who did not respond to the fax all weekend long. As a result, the resident did not receive his anti-seizure medications Friday or over the weekend. Reason listed in the Medication Administration Record of the resident’s chart was Drug Unavailable.
On Monday morning, the Director of Nursing contacted the attending physician’s office again at 8:30 a.m. The doctor’s office staff informed her that it may be a while before they get a response because they needed to sort through some 50 (!) faxes that came in over the weekend and the doctor would not be in until 10:45 a.m.
What happened as a consequence of this resident not receiving his anti-seizure medication? Over the course of the weekend, the staff documented the resident experiencing multiple seizures. Throughout the course of the day Monday, the resident had several additional seziures while the nursing home staff waited for a return call. Shortly after 1 pm, the nursing home had the resident sent to the hospital, after which time the doctor called back saying he was not comfortable issuing the prescription for the anti-seizure medications. At the hospital, the resident was sedated and intubated and given an EEG which confirmed that the resident had multiple seizures. Transfer to a larger hospital was recommended to treat the seziures caused by this nursing home medication error.
There are multiple issues with what transpired with this resident:
- When the hard copy of the prescription needed to order the medication did not arrive with the resident, the simplest course of action would have been to follow up with the hospital, but this was not done. Instead, they looked to the attending doctor from the nursing home (who, if you read the citation from the nursing home, was probably not expected to be very responsive) and who ultimately declined to get involved;
- When they could not get a response from the doctor, they failed to contact the medical director or the hospital to get assistance;
- Once the resident began to experience seizures, they failed to notify the doctor to get orders or instructions to get the resident to the hospital. As a result, the resident remained in the nursing home experiencing additional seizures.
Obtaining medications for nursing home residents who need them is a basic part of the services that nursing homes provide. Well-run businesses run on systems that provide the basic level of service without fail. The nursing home here quite clearly failed that task, much to the detriment of the resident.
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