Failure to Develop and Implement Comprehensive Seizure Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with epilepsy and other neurological conditions. The resident's clinical record showed diagnoses including epilepsy with status epilepticus, aphasia following a stroke, and hemiplegia/hemiparesis. The resident was prescribed multiple anti-seizure medications, including Depakote Sprinkles, lacosamide, and levetiracetam, as indicated by physician orders. Despite these diagnoses and treatments, there was no seizure care plan found in the resident's current record. During an interview, the Director of Nursing confirmed that a seizure care plan previously existed in the facility's old system but was not present in the current system. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for all identified needs. The absence of a seizure care plan for this resident constituted a failure to meet this policy and regulatory requirement.