Failure to Develop Comprehensive Care Plan for Resident with Seizure Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident 44, who was cognitively impaired and had a seizure disorder. The resident was receiving anticonvulsant medications, specifically valproic acid and levetiracetam, as per physician's orders. However, the resident's care plan did not include any documented evidence addressing the care needs related to the anticonvulsant medications or the seizure disorder. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have included the use of anticonvulsant medications and the seizure disorder. The facility's policy required that comprehensive care plans be developed and updated regularly to meet the resident's medical, nursing, and psychosocial needs, but this was not adhered to in the case of Resident 44.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #44 will have an anticonvulsant/seizure disorder care plan created. To identify other residents with the potential to be affected, the Director of Nursing/designee will review other residents on anticonvulsants and with a seizure disorder to ensure they have appropriate care plans in place. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure comprehensive care plans are in place. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.