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Based on review of the medical record and staff interviews, the Hospital failed to ensure that nursing staff documented pertinent clinical information regarding Patient #1's seizure and subsequent cardiopulmonary arrest with transfer to an acute care facility, for one of one applicable medical record, Patient #1.


Findings include:


Background information: The Hospital reported that on 01/05/12 at 12:50 P.M, Patient #1 [PT. #1] was found face down on the floor, unresponsive and pulseless after a seizure. Cardiopulmonary resuscitation was initiated and Pt. #1 was transferred with advanced life support to an acute care hospital and later expired. Pt. #1's history included traumatic brain injury and significant cardiac disease. Pt. #1 had multiple transfers to an acute care hospital secondary to seizure activity and clinical decline with readmission to the Rehabilitation Hospital. Hospitalist #1 said that Patient #1 complained of feeling anxious about being discharged to the skilled nursing facility later that day and reported that she/he felt like a seizure was imminent. The Nurse administered Ativan and in less than five minutes later, Patient #1 was found on the floor, actively seizing.

1) The Nurse Manager was interviewed in person on 01/30/12 from 9:40 A.M. to 9:55 A.M. and Licensed Practical Nurse #1 was interviewed in person on 01/30/12 from 2:00 P.M. to 2:15 P.M. respectively. Both said that Patient #1 came to the nursing station to say good bye to the staff prior to plans for transfer to a skilled nursing facility within the hour. Both said that Patient #1 reported to Certified Nursing Assistant (CNA) #1 that he/she felt "like having a seizure." Both said that Patient #1 was immediately returned to bed and Hospitalist #1 went in to conduct an evaluation.

2) Hospitalist #1 was interviewed in person on 01/30/12 from 10:50 A.M. to 11:00 A.M. Hospitalist #1 said that Patient #1 complained about feeling anxious about discharge to the skilled nursing facility. Hospitalist #1 said that she examined Patient #1 and was not concerned about the Patient's report regarding sensing an imminent seizure at the time of the evaluation. Minutes later, Patient #1 was found on the floor, having a seizure.

3) Review of Hospitalist #1's Progress Note dated 01/05/12 at 1:35 P.M. indicated that Patient #1 was found on the floor, actively seizing. Hospitalist #1 indicated that Patient #1 had been evaluated at 12:41 P.M. for being anxious and not feeling right. During the seizure, Patient #1 was observed to be breathing on his/her own, but not responding. Patient #1 was observed to gasp for air and became pulseless. Cardiopulmonary resuscitation was initiated. Patient #1 was intubated and placed on mechanical ventilation and medicated with Epinephrine and Atropine. Patient #1 was urgently transferred to an acute care hospital and later expired.

4) There were no documented nursing notes in the medical record between the dates of 12/22/11 to 01/05/11.

5) The VP of Nursing accompanied the Surveyor on 01/30/12 from 8:20 A.M. to 3:00 P.M. during the survey. The VP of Nursing said that the nursing notes were lost. However, Licensed Practical Nurse #1 said she documented a nursing note on 01/05/12.

6) Review of Patient #1's medical record indicated that there was no documented nursing assessment or notes dated 01/05/11 in Patient #1's record regarding a fall secondary to a seizure with subsequent cardiopulmonary resuscitation and emergent transfer to an acute care hospital. Patient #1 later expired.