Failure to Notify Physician of Recurrent Seizure Activity
Penalty
Summary
Licensed Vocational Nurse (LVN) 3 failed to notify the physician when a resident with a history of seizures experienced multiple seizure episodes on six separate occasions. The resident, who had severe cognitive impairment and required substantial assistance for mobility, was prescribed Ativan as needed for seizures. The Medication Administration Records (MAR) indicated that Ativan was administered on each of these occasions for seizure activity. However, aside from documenting the administration of Ativan on the MAR, LVN 3 did not document the seizure activity elsewhere in the resident's medical record, did not notify the physician, and did not complete Change of Condition (COC) assessments as required by facility policy. During interviews, LVN 3 confirmed that she followed the medication administration orders but did not inform the physician or complete the necessary assessments after each seizure event. The Assistant Director of Nursing (ADON) stated that a COC assessment should be completed for each seizure and that physician notification is necessary, especially if seizures occur despite medication. The facility's policy requires physician notification for changes in a resident's medical or mental condition. This failure to notify the physician prevented timely adjustments to the resident's plan of care.