Failure to Assess and Notify Physician After Resident-Reported Seizure Activity
Penalty
Summary
The facility failed to assess a resident and notify the physician after the resident self-reported seizure activity. The resident, who had a documented history of seizure disorder, multiple sclerosis, cerebrovascular accident, schizophrenia, and depression, was cognitively intact and reported experiencing multiple seizures per day. The care plan included specific interventions for post-seizure treatment, documentation, and seizure precautions, and there was a physician order to notify neurology if an increase in seizures was noted. Despite these directives, clinical record review showed only one documented note of a self-reported seizure during the review period, with no further documentation of seizure activity. Multiple staff interviews revealed that the resident frequently reported seizures to staff, who would either check on her or report to the charge nurse. However, nursing staff, including an RN and LPN, admitted to not notifying the neurology provider regarding the resident's reported increase in seizures, as required by the physician's order and facility policy. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify for changes such as increased seizure activity. Staff interviews indicated a lack of consistent assessment and documentation of the resident's reported seizures, and the required notifications to the physician or neurology provider were not made, despite repeated self-reports by the resident.