Portsmouth Health and Rehab: Unauthorized Seizure Drug - VA
The incident happened on April 25, 2025. A nursing assistant called LPN5 to the bedside after the resident, identified in inspection records as R13, showed signs of distress. What the nurse found was documented in a facility alert note: R13 was actively seizing in bed, head turned to one side, spitting, producing pink-tinged secretions from the mouth, unresponsive to his name, eyes moving rapidly, warm to the touch.
LPN5 called the on-call practitioner and left a message. Nobody called back.
Before the return call came, R13 seized again. LPN5 called for help from RN2 and dialed 911. At that point, RN2 noticed a vial of Ativan in the narcotic drawer of the medication cart. The medication had been discontinued. There was no active order for it. RN2 administered it anyway, injecting 0.5 cubic centimeters of the lorazepam into R13's right deltoid muscle. R13 continued seizing. EMS arrived and transported him to the hospital, where he was admitted for seizures.
The facility opened an internal investigation four days later. Its conclusion: RN2 had practiced outside her scope when she gave the discontinued drug without obtaining a new order.
LPN5 was suspended the night of the incident and fired on May 2. RN2 was removed from the schedule, and the staffing agency that placed her was told she was not to return to the facility.
What the investigation also found was that the discontinued Ativan had been sitting in the narcotic drawer in the first place. It should not have been there. The Director of Nursing who led the post-incident response, identified as DON2, audited the medication carts and oversaw the destruction of other discontinued narcotics that were found. All nursing staff were retrained the following day on physician orders, medication administration, and what to do with discontinued narcotics.
When inspectors returned to the facility in September, five months after the incident, a different Director of Nursing, DON1, explained how discontinued narcotics are supposed to be handled: pulled from the cart with a completed narcotic sheet and brought to her for destruction with a second nurse present. She said it was outside nursing scope of practice to give any medication without a physician's order.
The Medical Director told inspectors he expected nurses to obtain an order before administering any medication and that giving discontinued drugs was not within their scope of practice.
The Physician Assistant on staff said she had not been on call the night of April 25 but expected the same thing: call, get an order, then give the medication. She noted R13 had received lorazepam before, for agitation, without negative outcomes. That history did not change the requirement.
RN2, according to DON2's account to inspectors, acknowledged she gave the medication without an order. Her explanation was that it was an emergency.
CMS cited the facility under F0658, professional standards of care, noting minimal harm or potential for actual harm, with few residents affected. The citation reflects that R13 was seizing when the drug was given and was transported to the hospital, where he was admitted, though the inspection report does not describe lasting injury attributed directly to the unauthorized administration.
What the record does show is a discontinued narcotic left accessible in a medication cart, an on-call practitioner who did not answer, a nurse who made a decision in the middle of a medical emergency without authorization, and a second nurse who was fired for the role he played in getting the medication to the room.
R13 seized for four minutes, stopped for ten seconds, and seized again for five more minutes before the injection was given. EMS took over after that. The facility's own note on the night recorded it all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Portsmouth Health and Rehab from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA was cited for violations during a health inspection on September 19, 2025.
The incident happened on April 25, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.