Failure to Monitor, Assess, and Communicate After Seizure, Fall, and Medication Refusal
Penalty
Summary
The facility failed to provide necessary care and services for three residents reviewed for quality of care. For one resident with a seizure disorder, after experiencing a seizure, staff did not complete neurochecks, perform a thorough assessment, or conduct lab monitoring as required by the care plan and physician orders. There was no immediate notification to the resident's representative or physician regarding the seizure, and documentation of post-seizure monitoring was absent. Surveillance footage and interviews confirmed that staff did not intervene appropriately during or after the seizure, and the resident was later sent to the ER at the family's request due to concerns about a change in condition. Another resident who sustained a fall with a head strike and injury was not properly monitored upon return from the ER. The facility did not complete or document neurological checks as required by protocol for head injuries. Interviews with staff revealed a lack of clarity regarding the process for neurochecks and incident reporting, and the resident's hospital records were not initially available in the facility's chart. The resident was observed with a significant bruise and stitches above the eyebrow, but there was no evidence of the required post-fall neurological assessments being performed or documented. A third resident with dementia and bipolar disorder refused prescribed psychotropic and dementia medications since admission, but the facility failed to assess, intervene, or develop a plan of care in response to the ongoing medication refusal. This lack of intervention led to behavioral decompensation and ultimately required psychiatric hospitalization. The report details that these failures placed residents at risk for unmanaged medical and psychiatric conditions, with documentation and interviews confirming the lack of timely assessment, monitoring, and communication with medical providers and resident representatives.