ATHENS, GA - A critical medication error at Presbyterian Village Athens resulted in a resident experiencing a grand mal seizure after receiving the wrong dose of anti-seizure medication for nearly two weeks, according to a federal inspection report.
Dangerous Dosing Error Goes Undetected
The inspection revealed that a resident prescribed lamotrigine 250 mg extended release daily received only 25 mg per day - one-tenth of the prescribed dose - due to a pharmacy dispensing error that went unnoticed by nursing staff for 13 days. The resident, who had been admitted with a seizure disorder diagnosis, experienced a grand mal seizure as a direct result of the subtherapeutic medication level.
The medication error occurred when the facility's pharmacy incorrectly filled the prescription with 25 mg tablets instead of the ordered 250 mg extended release tablets. Multiple nursing staff administered the incorrect dose without verifying the medication against the physician's orders, violating fundamental medication safety protocols.
Critical Seizure Event Details
On the day of the seizure, a nursing alert documented the frightening medical emergency. The resident was being prepared for lunch when they "suddenly scream[ed] out with hands wide and proceeded to have what this writer would assess, as a grand mal seizure."
The documentation described severe physical manifestations: "Her back arched, feet turned downward, and eyes rolled upwards. Clenched her jaw, head was extended back and exhibited difficulty in breathing due to airway issue."
Nursing staff immediately placed the resident on their side to address airway concerns, which helped restore normal oxygen saturation and skin color. The seizure lasted several minutes, followed by a postictal state where the resident's pupils were initially unresponsive before gradually returning to normal.
Lamotrigine: Why Precise Dosing Matters
Lamotrigine is an anti-seizure medication that requires precise dosing to maintain therapeutic blood levels. The drug works by stabilizing electrical activity in the brain, but effectiveness depends on consistent, adequate dosing. When levels drop below therapeutic range, breakthrough seizures can occur.
The tenfold dosing error was particularly dangerous because lamotrigine has a specific dose-response relationship. A 25 mg dose would be considered a minimal starting dose for certain conditions, while 250 mg represents a full therapeutic dose for seizure control. The dramatic difference meant the resident was essentially unprotected against seizure activity.
Anti-seizure medications like lamotrigine must be maintained at steady blood levels to prevent breakthrough seizures. Even minor interruptions in proper dosing can trigger seizure activity in susceptible individuals, making medication accuracy critical for this vulnerable population.
Staff Training and Protocol Failures
The inspection revealed significant gaps in medication administration training and supervision. One registered nurse admitted she "did not follow the five rights of medication administration" - a fundamental nursing practice requiring verification of right patient, right medication, right dose, right route, and right time.
The nurse explained that because residents sometimes receive low doses of lamotrigine for behavioral management, she "didn't think anything about her taking 25 mg instead of 250 mg." This assumption violated basic medication safety protocols requiring verification of each dose against physician orders.
Another licensed practical nurse told inspectors she had "not been provided any education on medication administration" and that "no one in the facility has observed medication pass with her." This lack of training and supervision represents a systemic failure in ensuring qualified staff handle critical medications.
Facility Policy vs. Practice Disconnect
Presbyterian Village Athens maintained comprehensive medication policies requiring adherence to the "five rights" of medication administration. The facility's pharmacy policy emphasized that "the RIGHT medication must be given to the RIGHT patient in the RIGHT dose at the RIGHT time, using the RIGHT method of administration."
However, the inspection found a significant gap between written policies and actual practice. The Director of Nursing confirmed that while the facility had detailed medication management policies, staff were not consistently following these protocols.
The pharmacy director noted that medication administration policies should be available at each nursing station, but interviews revealed inconsistent staff knowledge and application of these guidelines.
Additional Dietary Management Deficiency
The inspection also identified that the facility's dietary department lacked properly certified leadership. The dietary manager had no certification or relevant education degree, despite federal requirements for qualified food service management.
The dietary manager admitted she was not yet certified but planned to enroll in certification courses. The executive director acknowledged awareness of this deficiency but incorrectly stated that certification was not currently required.
This finding represents another area where the facility failed to maintain required staffing standards, potentially impacting resident nutrition and food safety protocols.
Medical Oversight and Quality Assurance
The medication error highlighted weaknesses in the facility's quality assurance systems. Multiple opportunities existed to catch the dispensing error, including initial medication setup, daily medication passes, and routine medication reviews.
Proper medication management requires multiple verification steps: pharmacy dispensing accuracy, nursing verification against orders, and ongoing monitoring for therapeutic effectiveness. The failure of these safeguards allowed a dangerous error to persist for nearly two weeks.
The incident also raised questions about medical oversight, as the resident's seizure disorder required careful monitoring of medication effectiveness and potential breakthrough symptoms.
Regulatory Standards and Expectations
Federal nursing home regulations require facilities to ensure residents are free from significant medication errors. This includes proper medication storage, accurate administration, and ongoing monitoring for therapeutic effectiveness and adverse reactions.
The Centers for Medicare & Medicaid Services expects facilities to maintain comprehensive medication management systems, including staff training, quality assurance protocols, and clear policies governing all aspects of medication handling.
When medication errors result in actual harm - as occurred in this case - facilities face enhanced scrutiny and potential sanctions for failing to protect resident safety and welfare.
Impact on Resident Safety
Grand mal seizures pose serious health risks, particularly for elderly residents who may have multiple medical conditions. The seizure could have resulted in serious injury from falls, breathing difficulties, or other complications.
The 13-day period of inadequate seizure protection left the resident vulnerable to breakthrough seizure activity that could have occurred at any time, potentially during activities that might have resulted in additional injury.
The incident represents a preventable adverse event that occurred due to system failures rather than unavoidable medical circumstances, making it particularly concerning from a patient safety perspective.
Facility Response and Corrective Measures
Following the incident, the facility provided additional staff education on medication administration principles, including proper verification procedures and the importance of matching medication orders with dispensed medications.
The Director of Nursing confirmed that nursing staff received training on the five rights of medication administration and the requirement to check medications against orders before administration.
However, the inspection findings suggest the need for more comprehensive system changes to prevent similar errors, including enhanced pharmacy oversight, improved quality assurance protocols, and regular competency verification for medication-administering staff.
The incident serves as a reminder of the critical importance of medication safety protocols in long-term care facilities, where residents depend on staff to accurately manage complex medication regimens that directly impact their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presbyterian Village - Athens from 2024-07-22 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.