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Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure the nursing staff developed, and kept current, a nursing care plan related to Seizure Disorder for one patient (#1), in the selected sample of ten patients. Patient #1 was admitted to the facility on 08/31/12, with a diagnosis to include Seizure Disorder. There was no evidence the facility had developed or implemented a care plan related to the patient's seizure disorder.

Findings include:

A review of the facility's policy/procedure, "Treatment Plans," last revised 02/12, revealed "a preliminary treatment plan is developed upon admission by the assessing therapist and is based on psychosocial assessment findings of the individual's presenting problems, physical health, emotional and behavioral status. Problems are identified based on individual/family or guardian input and suggested goals and focus of treatment are based on assessed needs."

A record review revealed the facility admitted Patient #1 on 08/31/12 with Axis III diagnosis to include Seizure Disorder, by history.

A review of the Medication Administration Record (MAR), dated 09/01/12, revealed the patient received Depakote Extended Release (ER) 1000 milligrams (mg) by mouth (po) at hour of sleep (HS) for seizure disorder.

An interview with the Nurse Manager, on 02/15/13 at 10:55 AM, revealed she completed Patient #1's initial nursing assessment upon admission, on 08/31/12; however, she stated she was not informed about the patient's seizure history at that time. She stated that Licensed Practical Nurse (LPN) #1 completed an admission nursing assessment on 08/31/12, once the patient arrived to the unit.

A review of Patient #1's admission nursing assessment, completed by LPN #1 on 08/31/12, revealed his/her current medical problems and medical history included seizures. An attempt to contact LPN #1, on 02/15/13 at 1:30 PM and 2:30 PM, was unsuccessful.

An interview with Registered Nurse (RN) #1, on 02/12/13 at 4:05 PM, revealed when the patient was first admitted to the facility, he/she would get up in the middle of the night stating he/she had a seizure, and she documented this information; however, RN #1 stated she did not witness any seizure activity.

An interview with LPN #2, on 02/13/13 at 3:40 PM, revealed she did not observe evidence of Patient #1's seizure activity; however, she stated "I received a phone call from [his/her] parent on 09/03/12, who told me that, at night, if [he/she] screamed, this would be indicative of a seizure," and stated she shared this information with the oncoming shift.

An interview with RN #2, on 02/13/13 at 11:40 AM, revealed she was aware of the patient's history of seizures. She stated there were two occasions on 11:00 PM - 7:00 AM shift when the patient came out of his/her room crying. The patient was given a cool cloth, but he/she could not describe what was wrong; however, "[he/she] never mentioned a seizure to me, just seemed scared."

An interview with the Physician, on 02/12/13 at 1:00 PM, revealed Patient #1 reported to him that he/she was having seizures. The physician stated he asked Patient #1 to describe the seizure activity and events to him, and to let the nurses know when it happened. The Physician stated he did not witness any seizure activity during the patient's stay at the facility.

An interview with the Neurologist, on 02/13/13 at 2:57 PM, revealed Patient #1 was started on Depakote for seizure activity in 2009, and continued on this medication since that time. He continued to follow the patient's case, and stated that, in July 2012, the patient's parent brought him/her to see the Neurologist. He stated the patient had no grand mal seizure in over a year; however, he/she remained on Depakote.

A review of the Admission Initial Treatment Plan, dated 08/31/12, and a review of the Master Treatment Plan, dated 09/04/12, revealed no evidence of a care plan related to the patient's seizure disorder.

An interview with the Therapist, on 02/15/13 at 10:40 AM, revealed upon admission on 08/31/12, the therapist developed an initial treatment plan. A master treatment plan, dated 09/04/12, was developed by the patient's primary Therapist, Nursing, Recreational Therapist, Physician, School Principal, and the Case Manager. The patient came in to the facility, the plan was reviewed with the patient, and the patient signed the plan. The plan was also reviewed with the family during the initial session (within 1-2 days after admission). The Therapist does not address medical issues in their portion of the treatment plan. After initial treatment, it was reviewed at the 7-day mark. She stated, "I continued [his/her] goals due to behavior issues, working on short-term and long-term goals."

An interview with the Administrator, on 02/15/13 at 10:50 AM, revealed the process for development of treatment plans included the following: the initial treatment plan was completed in three days by a therapist, whereby nursing addressed the medical portion. In ten days, the master treatment plan was completed by each team member, and a master treatment review was completed in thirty days from admission to see if issues were still relevant. She revealed there was no protocol specific to seizures, and was unable to provide anything in writing related to seizure protocol. She stated, "to my knowledge, we do not develop care plans specific to seizure disorder, and typically a patient would already have a care plan developed by [his/her] neurologist." Additionally, she stated there was no evidence of a care plan related to seizures for Patient #1, and was unable to provide further explanation. She stated "we just knew that everyone knew about seizures."