Failure to Notify Provider and Representative After Seizure and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider and resident representative of a resident’s change in condition following a seizure event, and failure to document the event and related care. Resident #9, admitted on 10/19/22 with diagnoses including epilepsy and moderately impaired cognition per the MDS, had a care plan revised on 10/17/25 that directed staff to monitor and report any seizure activity and to report abnormal vital signs to the physician. Despite this, review of progress notes from 01/07/25 to 01/14/25 showed no documentation of a seizure or any notification to the provider or resident representative. The DON confirmed there was no documentation of the seizure that occurred on 01/12/26 and no documentation of notification to the provider or resident representative, and also confirmed there was no order for oxygen in the resident’s record. Staff interviews further detailed the unreported and undocumented change in condition. One LPN stated that Resident #9 had a seizure on the night of 01/12/26 lasting about five minutes, during which the resident had difficulty breathing while lying on his back; the LPN administered scheduled Keppra and applied oxygen at 2.5 liters, even though the resident did not have an oxygen order and did not normally require oxygen. The LPN reported believing another LPN had obtained an oxygen order from the provider while he was in the room, but the second LPN later confirmed he did not notify the provider and did not speak to the provider about oxygen. The NP confirmed she was not notified of the seizure until 01/14/26 and stated that, had she been informed at the time, labs would have been ordered. Review of the facility’s “Acute Condition Changes Clinical Protocol” dated 03/2018 showed that nursing staff are required to contact the physician based on the urgency of the situation and discuss possible causes and needed diagnostic tests, which did not occur in this case.
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