Failure to Notify Physician and Responsible Party After Resident Seizure
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a significant change in condition following a witnessed seizure. The resident, an elderly female with multiple comorbidities including anemia, hyperlipidemia, major depressive disorder, insomnia, hypertensive heart disease, hemiplegia, acute respiratory failure, GERD, osteoarthritis, and muscle wasting, had no documented history of seizure disorder upon admission. Despite this, she was on anticonvulsant medication and had a care plan in place for seizure management. On the morning of the incident, staff observed the resident experiencing a seizure, including foaming at the mouth and shaking, but did not immediately notify the physician or the resident's responsible party as required by facility policy and federal regulations. Following the seizure, staff failed to initiate neurological checks, perform a thorough assessment, or obtain laboratory work as outlined in the resident's care plan. Documentation in the medical record did not reflect any neurochecks or post-seizure monitoring. The responsible party and physician were not informed of the event in a timely manner. The resident remained without clinical intervention until later in the day when the family, after observing concerning behavior on a room camera, requested a hospital transfer due to the unaddressed change in condition. Interviews with staff revealed that the charge nurse did not notify the physician or responsible party, citing workload and time constraints, and the ADON and DON were under the impression that notifications had been made when they had not. Video surveillance and interviews confirmed that the resident exhibited seizure activity and post-ictal symptoms, including foaming at the mouth and minimal responsiveness, for several hours without appropriate clinical response or notification. The responsible party only became aware of the situation after viewing the camera footage and contacting the facility, at which point the resident was transferred to the hospital. The facility's failure to follow established protocols for notification and post-seizure care resulted in a deficiency, as it did not ensure timely medical evaluation or involvement of the responsible party in care decisions.