F0684

J

Failure to Notify Physician of Resident’s Acute Neurological Change and Possible Seizure

Muleshoe, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the resident’s person-centered care plan when a resident experienced a significant change in condition. The resident was an elderly female with multiple serious diagnoses, including dementia, chronic kidney disease stage 4, atrial fibrillation, chronic respiratory failure with hypoxia, seizure disorder related to prior meningioma resection, multiple fractures, COPD, hypertension, and long-term anticoagulant use. Her care plan included detailed interventions for seizure disorder, post-seizure treatment, seizure documentation, and seizure precautions, as well as monitoring and physician notification requirements for hematologic status, cardiac issues, and altered respiratory status. She was a DNR and the only listed responsible party.

On the night in question, nursing notes documented that the DON was called to the resident’s room by CNAs at approximately 4:30 a.m. because the resident was unresponsive. The DON documented that the resident would not respond, but vital signs were within normal limits, breathing was not labored, and the resident appeared to be resting comfortably. The DON instructed CNAs to increase monitoring and report any changes. A short time later, around 4:40 a.m., the DON was called back due to blood in the resident’s mouth; after cleaning, it was apparent the resident had bitten her bottom lip. The DON documented that the lip and mouth were cleansed, no further bleeding was noted, and the resident was still sleeping very soundly with no distress noted. The physician was not contacted at either time despite the resident being unresponsive and having bitten her lip.

In subsequent interviews, the DON acknowledged that at around 4:30 a.m. the resident was unresponsive but breathing, was not acting right, and only opened her eyes slightly to a sternal rub, with no other response to questions. The DON stated she did not call the physician because it was early in the morning, but that she should have done so at that time and again when blood was noted on the resident’s mouth. The DON reported that she gave report to the oncoming LVNs, told them she thought the resident was septic, and that vital signs were still normal, so the LVNs decided to monitor the resident. Later that morning, the resident’s condition worsened; during peri care she had seizure activity, became unresponsive with shallow, labored respirations, and EMS was called for transport to the hospital. Hospital records documented a large intracerebral hemorrhage and that the resident was minimally responsive and later died. The resident’s physician stated that if he had been notified that the resident was unresponsive and had possibly bitten her lip, he would have had her sent to the hospital immediately. The facility’s own policy on acute condition changes required nursing staff to contact the physician based on urgency, including for significant changes in neurological status and level of consciousness, which did not occur in this case.

This failure to notify the physician of the resident’s unresponsiveness and possible seizure activity (evidenced by lip biting) constituted the basis of the deficiency under F684 for not providing care and services in accordance with professional standards and the resident’s care plan. The surveyors determined that because the physician was not contacted or included in the resident’s change of condition, she did not receive the best care available. An Immediate Jeopardy was identified related to this failure, later removed after the facility implemented a plan of removal, but the facility remained out of compliance at a lower severity level pending evaluation of the effectiveness of corrective systems.