The medication shortage forced the resident to transfer to another facility.
Federal inspectors found that Resident B, who has a documented seizure disorder, missed at least two doses of lacosamide in late October. The 50-milligram tablets were prescribed twice daily — morning and bedtime — according to physician orders from August 15.
The facility's medication administration records showed no documentation that staff gave the resident the bedtime dose on October 24 or the morning dose on October 25. A progress note from October 25 at 9:08 a.m. revealed why: the medication was unavailable, and the pharmacy said a new prescription was needed.
The resident transferred out of the facility that same day.
Lacosamide is an anti-seizure medication used to control partial-onset seizures in adults and children. Missing doses can trigger breakthrough seizures, particularly dangerous for residents with established seizure disorders who depend on consistent medication levels.
During interviews with inspectors, the Corporate Nurse Consultant acknowledged the breakdown in medication management. She explained that the medication came from the pharmacy on a card system that allowed nurses to visually track when refills would be needed.
The consultant told inspectors that the pharmacy actually had a prescription with refills available for the medication. Despite this, the facility somehow failed to obtain the refill before running out completely.
Adding insult to injury, the medication finally arrived from the pharmacy after the resident had already been forced to transfer to another facility on October 25.
The inspection narrative doesn't detail what triggered the resident's transfer or whether the medication shortage was the primary reason. But the timing suggests the facility's inability to provide prescribed seizure medication may have necessitated moving the resident to a facility that could meet their basic pharmaceutical needs.
The Corporate Nurse Consultant's explanation raises questions about the facility's medication monitoring systems. If nurses could "visualize when a refill would be needed" and the pharmacy had refills available, the breakdown appears to have occurred in the facility's internal processes rather than external supply chain issues.
Federal regulations require nursing homes to provide pharmaceutical services that meet each resident's needs. This includes employing or contracting with licensed pharmacists and maintaining adequate medication supplies. The inspection found Brickyard Healthcare failed this basic requirement for at least one resident with a serious neurological condition.
The violation was classified as causing "minimal harm or potential for actual harm" affecting "few" residents. However, for Resident B, the consequences were immediate and disruptive — missing critical seizure medication and having to leave the facility entirely.
The inspection was conducted as a complaint investigation, suggesting someone reported concerns about medication management at the facility. The specific complaint that triggered the investigation isn't detailed in the available records.
Brickyard Healthcare - Portage Care Center must submit a plan of correction to address the medication management failures identified during the inspection. The facility has 14 days from receiving the inspection report to make these findings public.
For families of residents taking anti-seizure medications or other critical drugs, this case highlights the importance of monitoring medication administration closely. Missing doses of seizure medications can have serious consequences, and facilities must maintain reliable systems to prevent such gaps in care.
The resident's transfer to another facility represents the human cost of administrative failures in nursing home pharmaceutical services. What should have been a routine refill became a forced relocation for someone who needed consistent, specialized care for a chronic neurological condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brickyard Healthcare - Portage Care Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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