IDPH has cited and fined Sharon Health Care Elms nursing home in Peoria after a resident there suffered seizures due to not receiving anti-seizure medications as ordered.
Treating seizures is a difficult task but must be done. Prolonged seizures can cause brain damage but even shorter seizures can cause injury and have lasting effects. The most effective way to prevent seizures is through the use of medication, often given in combination. Nursing home medication errors which result in residents not receiving their medications as ordered can result in significant seizures with serious resulting injuries.
The resident at issue had a diagnosis of epilepsy as well other neurologic disorders which affected the brain. She was prescribed multiple medications, including Keppra and Depakote to help prevent seizures.
Over a period of approximately 6 hours, the resident experienced four seizures. The shortest of these was 90 seconds, the longest approximately 5 minutes. Two occurred in the nursing home, one in the ambulance on the way to the hospital, and the last in the emergency room.
When the resident arrived in the emergency room, labs were drawn. These showed that the resident’s Depakote levels were 13 mcg/ml (normal range 50-100) and that Keppra could not be detected at all. The conclusion was that the resident’s seizures were due to subtherapeutic (below normal) levels of these anti-seizure medications.
Investigation into this incident showed that the Keppra had been discontinued due to a clerical error by a member of the nursing staff. An error had been made in entering the order for the Keppra. The wrong order was discontinued; however the correct order was not entered. The net result was that no Keppra was being given to the resident. This is of course consistent with lab results showing that Keppra could not be detected at all.
The issue with the Depakote is more difficult to determine how the resident ended up with subtherapeutic levels of the medication. However, the last delivery of Depakote was made to the nursing home from the pharmacy a little less than a month and a half prior to the date that the seizures occurred. However, the container only had enough medication to last 18 days. Clearly there was not enough medication on hand for the resident to be receiving the medication as ordered, resulting in the below-normal levels of this medication as well.
Giving medications as ordered is one of the basic tasks in a nursing home, and this incident demonstrated two clear but critical breakdowns in the delivery of medication to this resident. One, relating to the Keppra, was the result of simple clerical error. However, in well-run nursing homes, entries as to medication orders are normally double checked after the order is entered by a nurse on the floor. The other medication error, relating to the Depakote, was likely multi-factorial but likely involves some element of false charting by the nursing home staff.
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