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Compliance Inspector (CI) Jessica Graham investigated the allegation that teacher, Audrey, administered 25 milliliters of Benadryl to Child A, female, who required only a 2.5 milliliter dosage. Child A was hospitalized as a result of the improper dosage. This allegation is substantiated based on the following rule violation.
5 CSR 25-500.192(3)(D)., which states: "All nonprescription medication shall be in the original container and labeled by the parent(s) with the child's name, and instructions for administration, including the times and amounts for dosages."
On July 10, 2024, Audrey Seiver stated that this was the first time she had administrated medication to a child and when giving Child A her medicine, she looked too quickly at the form and gave her the wrong dosage. Child A was supposed to get 2.5mL of medicine as documented by Parent A but Audrey gave her 25mL. Immediately she knew that she had messed up and called Jamison Lewis, director, to let her know what happened. Parent A was notified and Child A was monitored and given water until picked up by Parent A.
Jamison said that she will be having a meeting to go over medication administration with all caregivers and will be revamping their policies on medication administration in their handbook.
Parent A had written instructions for the medication as well as sent a text message for administering. She was alerted within a few minutes after Child A received the wrong dosage. She felt that the caregivers handled the situation appropriately and does not have any concerns with the care Child A receives.
On July 10, 2024, CI Graham observed messages between Parent A and Vasaio Atelier. The messages read as follows:
7/3/24 @ 12:42pm-Parent A
"How is Child A doing? Were you able to give her bendryl at 11 today?"
7/3/24 @ 12:43pm-Brittni Brasher, caregiver
"Hey Parent A, we did not. I must have misheard this morning and I thought you said if we felt that she needed it. She has been great today and hasn't scratched her rash or said anything about it. I see the note in her bad does say to give at 11 so that is my fault. Would you like her to have it now or for us to skip?"
7/3/24 @ 12:44pm-Brittni Bresher, caregiver
"If we give it to her, we will have that med form ready for you also."
7/3/24 @ 12:49pm-Parent A
"It's ok! Yes please giver her 2.5 ml now:) and I'll sign form at pick up. Thanks so much:)"
7/3/24 @ 12:521pm-Brittni Bresher, caregiver
"You're welcome Brittany, and I'm sorry about that! We will give it to her now"
7/3/24 @ 12:52pm-ParetntA
"It's ok, I may have been unclear about it too. Thank you:)"
7/3/24 @ 1:10pm-Jamison Lewis, director
"I recorded the does that was received for her records."
7/3/24 @ 1:12pm-Jamison Lewis, director
"Also: 1-800-222-1222-Poison Control Hotline with free nurse line. Let me know if you'd like me to call. I'd need to know her estimated weight."
7/3/24 @ 1:17pm-Parent A
"I'll be there in five minutes, can you please have her ready at the door?"
7/3/24 @ 1:21pm-Jamison Lewis, director
"Yes"
7/3/24 @ 1:21pm-Audrey Sevier, caregiver
"Yes"
7/3/24 @ 4:39pm-Morgan Van Leer, caregiver
"Hey! We wanted to check in and see how Child A is doing!?"
7/3/24 @ 4:58pm-Parent A
"We just left the er. She is gonna be fine. Very tired. Poison control and er said it wasn't quite enough to be toxic
On July 10, 2024, CI Graham observed the Medication Authorization form. The form stated the medication name "Diphenhydramine HCL" for Child A dated 7/3/204. Dosage was 2/5mL one time per day. Side effect listed was drowsiness. The signature on the form appeared to be Parent A.
There was not an end date of administration listed on the form and the time of day for administration was not specific.
Audrey Sevier documented that she administered 25 mL of Diphenydramine HCL at 12:50 to Child A on 7/3/24.
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