Failure to Initiate Timely Seizure Monitoring Orders After First Seizure
Penalty
Summary
The facility failed to ensure that a resident with a history of seizures had appropriate physician orders to monitor for seizure activity following the resident's first documented seizure. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced a seizure lasting three minutes. Despite this event, there were no orders in place to monitor for further seizure activity until a later date, leaving a gap in monitoring and documentation. Record review and staff interviews confirmed that nursing staff did not contact the physician for seizure monitoring orders immediately after the initial seizure episode. The facility's own policy required staff to monitor and document seizure activity for individuals with new seizures or seizure disorders, but this protocol was not followed in a timely manner for the resident in question.