| 6400.186 | Individual #1 has a seizure protocol in place that if Individual #1 continues to seize for 15 minutes total- staff are to call 911 and continue with CPR/1st aid as needed. The following dates staff documented that Individual #1 had 2 seizures lasting more than 15 minutes. Staff did not follow the seizure protocol to call 911 for the 2 seizures lasting 15 minutes or longer.
6/1/22-5:45am-19 minutes 3 dosages of prn administered.
5/2/22-4:15am-15 minutes-2 dosages of prn med administered. | The home shall implement the individual plan, including revisions. | This regulation is important because it provides clear and unequivocal expectations for meeting each individual's needs and who is responsible for meeting each need.
On 6/1/2022 and 5/2/2022, it is documented that Individual #1 had a seizure that lasted longer than 15 minutes. According to the seizure protocol, 911 should be called if the seizure lasts 15 minutes or longer. The staff failed to contact 911.
During the 6/1/2022 seizure, staff documented that Individual #1 started seizing at 5:45am. The staff implemented the protocol and Individual #1 started coming out of his seizure at 6:01am. Although there was no medical impact to Individual #1, staff should have called 911 at 6pm.
During the 5/2/2022 seizure, staff documented that Individual #1 started seizing at 4:16am. It is unclear at what time Individual #1 started coming out of the seizure, but the report indicates that the entire episode lasted 19 minutes. Staff should have called 911 at 4:31am and failed to do so. There was no medical impact to Individual #1, but staff failed to follow the protocol.
Immediately following the inspection, the Agency Nurse received feedback from the team regarding the challenges with timing when to swipe the VNS, administer the PRN, and call 911. The protocol was updated on 3/20/2023 to address this challenge. Rather than waiting 5 minutes after the 3rd dose of his PRN is administered, staff are now expected to administer the 3rd dose of his PRN and call 911 immediately after. See Attachment #16 for the updated protocol and proof of training.
It was also determined that the Program Specialist and Agency Nurse responsible for reviewing Individual #1's seizure activity failed to acknowledge that the protocol was not followed on 6/1/2022 and 5/2/2022. All Program Specialists and Agency Nurses were retrained on the expectations of reviewing seizure reports when they are submitted and comparing the report to the protocol to ensure the protocol was implemented as written. This retraining occurred on 3/20/2023 and Attachment #4 is proof of training. |
03/29/2023
| Implemented |