SEATTLE, WA - A federal inspection revealed that medication administration failures at Seattle Medical Post Acute Care led to a resident's hospitalization with suicidal ideation after missing four consecutive doses of critical psychiatric medication.
Four-Day Medication Gap Leads to Crisis
The March 27, 2025 inspection documented how a resident with schizophrenia and a tracheostomy went without clozapine, a powerful antipsychotic medication, from February 22-25, 2025. The medication administration record showed the drug was "on order from pharmacy" during this period, indicating it was unavailable at the facility.
Two registered nurses failed to follow proper protocols when the medication was unavailable. Neither contacted the prescribing physician nor implemented alert monitoring procedures required when critical medications are missed.
Progressive Behavioral Deterioration
The resident's condition deteriorated rapidly during the medication gap. On February 24, nursing notes documented increased anxiety, prompting orders for hydroxyzine. By February 26, the resident was "walking back and forth on unit" with continuing anxiety, requiring additional anti-anxiety medications including lorazepam.
Social services notes from February 26 described observing the resident "pacing down the hallway" throughout the day. The resident communicated feelings of anxiety by writing on a notepad when approached by staff. This pacing behavior continued into February 27 in common areas of the facility.
A physician's note from February 27 detailed the full scope of symptoms: "anxiety, insomnia, racing thoughts, and confusion, irritability, pacing up and down the hallways" after missing four days of clozapine.
Emergency Hospitalization Required
On March 1, 2025, the resident expressed suicidal ideation with altered mental status, necessitating immediate hospitalization. Emergency department records confirmed the resident "expressed that he was suicidal without a plan."
Hospital psychiatry notes revealed the severity of the situation, documenting that the resident required Ativan for agitation, including "pulling at trach" (tracheostomy tube) and psychomotor agitation attributed to the decreased clozapine levels.
Medical Significance of Clozapine Interruption
Clozapine is prescribed specifically for treatment-resistant schizophrenia and requires consistent daily administration to maintain therapeutic blood levels. The medication has a relatively short half-life, meaning blood levels drop rapidly when doses are missed.
Interrupting clozapine therapy carries significant risks. When therapeutic levels drop, patients can experience rapid return of psychotic symptoms including hallucinations, delusions, agitation, and in severe cases, thoughts of self-harm. The medication must be carefully restarted with gradual dose increases to avoid serious side effects.
Medical protocols require immediate physician notification when clozapine cannot be administered, as alternative medications or emergency interventions may be necessary to prevent symptom deterioration.
Staff Acknowledge Protocol Failures
During interviews, facility staff confirmed the severity of the medication error. The consultant pharmacist stated that missing four doses "would be an issue and would see symptoms like hallucinations, agitation, and delusions" and confirmed this constituted a significant medication error.
The facility physician described missing four doses as "a big cause for concern" and called the situation "very unfortunate." The physician assistant who treated the resident's increasing symptoms stated they were not informed about the missing clozapine doses until February 26, after the behavioral changes had already begun.
The Resident Care Manager acknowledged that proper protocols were not followed, stating "you can't just not give it if there's an order, there's steps to take, call pharmacy, have to make the doctor aware."
Facility Response and Corrective Actions
The facility conducted an immediate medication error audit covering January through March 2025 and provided staff education on medication administration procedures and protocols for unavailable medications.
Weekly audits were implemented for four weeks followed by monthly audits for two months, with results reviewed through the facility's Quality Assurance Performance Improvement Committee.
The facility's investigation report confirmed that both nurses involved failed to notify the physician and implement required alert monitoring when the medication was unavailable.
Regulatory Standards for Medication Management
Federal regulations require nursing homes to ensure residents are free from significant medication errors. Facilities must have systems to prevent medication omissions and ensure immediate physician notification when prescribed medications cannot be administered.
The violation was classified as causing "actual harm" to the resident, reflecting the serious medical consequences of the four-day medication gap that directly led to behavioral deterioration and hospitalization.
This incident highlights the critical importance of robust medication management systems in nursing homes, particularly for residents with complex psychiatric conditions requiring consistent therapeutic medication levels.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seattle Medical Post Acute Care from 2025-03-27 including all violations, facility responses, and corrective action plans.
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