Elevate Health: Seizure Medication Error - NC

Resident #98 needed lacosamide, a controlled substance used to prevent seizures, but the facility ran out on January 14, 2025. The morning brought no medication from the pharmacy. By later that same day, the resident was seizing.

The administrator told inspectors that Nurse #1 had contacted Medical Director #1, who was in the building that morning, about the missing lacosamide. The medical director sent a prescription to the pharmacy. But the medication never arrived, and the resident seized anyway.

Medical Director #1 attempted to stop the seizure at the facility but was unsuccessful. Emergency medical services transported Resident #98 to the hospital.

The administrator called the medication lapse "a significant medication error." She explained that nursing staff should have contacted the pharmacy before the medication ran out and should have notified the provider that a new prescription was needed before supplies were exhausted.

During the medication shortage, someone had placed a hold order with the pharmacy. The administrator thought it was Nurse #1 who had called the pharmacy during the hold process and was told the medication was coming. But the assumption proved wrong.

The facility's backup medication system did not stock lacosamide. This left Resident #98 completely dependent on the pharmacy delivery that never came.

The administrator said the assigned nurse bore responsibility for contacting the provider when prescriptions were needed. When the medication failed to arrive from the pharmacy, the nurse should have escalated the problem by informing the director of nursing or management.

The facility held morning clinical meetings attended by the director of nursing, unit manager, or staff development coordinator. The administrator believed Resident #98's missing lacosamide had been mentioned in the morning clinical meeting. But staff assumed that since a hold order had been obtained from the physician, the doctor was aware and the medication was being delivered.

That assumption left Resident #98 without seizure protection.

The administrator acknowledged systemic failures in nursing processes. She said nurses were not following established protocols for medication management. There was inadequate oversight by the former director of nursing. Clinical meetings lacked thoroughness.

These deficiencies prompted management changes. Corporate management had been working inside the building to implement corrections.

The administrator emphasized that the nurse should have been persistent in obtaining the controlled prescription for lacosamide. She described it as the nurse's duty to secure the medication.

Federal inspectors classified the violation as immediate jeopardy, meaning the facility's failures placed residents at serious risk of harm or death. The designation affects few residents but represents the most severe category of nursing home violations.

The administrator received notification of the immediate jeopardy finding on August 27, 2025, at 5:40 PM. The facility submitted a corrective action plan with a correction date of January 22, 2025.

The inspection narrative cuts off mid-sentence while describing the facility's corrective measures, leaving the specific remedial steps unclear from the available records.

Lacosamide is prescribed for partial-onset seizures and works by stabilizing hyperexcitable neurons. Missing doses can trigger breakthrough seizures in patients who depend on the medication for seizure control.

The case illustrates how medication management failures can cascade into medical emergencies. The resident's seizure required not just emergency transport but also hospital-level intervention when the nursing home's attempts to stop it proved ineffective.

The timing suggests the facility's problems extended beyond a single medication error. The administrator's description of poor oversight, inadequate clinical meetings, and nurses not following processes points to broader systemic issues that required corporate intervention and management changes.

The immediate jeopardy classification puts Elevate Health and Rehabilitation under heightened federal scrutiny. Facilities with this designation face potential termination from Medicare and Medicaid programs if they fail to correct violations promptly.

For Resident #98, the consequences were immediate and frightening. What should have been a routine medication delivery became a medical crisis requiring emergency intervention and hospitalization.

The facility's backup systems failed when they were needed most. No lacosamide in the emergency medication supply. No effective escalation when the pharmacy delivery didn't arrive. No intervention despite morning clinical meetings where staff discussed the missing medication.

The administrator's acknowledgment that this represented a significant medication error underscores the severity of the lapse. In nursing homes, where residents depend entirely on staff for life-sustaining medications, such failures can prove catastrophic.

Resident #98's seizure stands as evidence of what happens when assumption replaces action in medication management. Staff assumed the medication was coming. They assumed the doctor was aware. They assumed the hold order meant the problem was being solved.

The resident paid the price for those assumptions with a seizure that required emergency hospitalization.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Elevate Health and Rehabilitation from 2025-09-02 including all violations, facility responses, and corrective action plans.

Additional Resources

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