The incident involved a resident with Alzheimer's disease and a seizure disorder who was completely dependent on staff for all daily care activities. Nursing assistants reported the patient was having seizures, but the supervising nurse's response violated multiple facility policies and left the resident without proper medical evaluation.
Staff B, the registered nurse on duty, told inspectors she went to assess the resident after nursing assistants reported seizure activity. She found the patient with eyes open, appearing at "normal baseline." Based on her brief observation, she decided to administer intramuscular Ativan, an anti-seizure medication.
The medication had expired.
Staff B discovered the expiration when she prepared to inject the drug and chose not to give it. But she also failed to return for additional assessments or provide alternative care, telling inspectors she "wasn't feeling well and could not walk."
The resident's care plan, initiated earlier that year, specifically directed staff to assess the patient "as soon as possible if seizure activity occurred." Progress notes from 3:22 AM documented that nursing assistants had reported "pre-seizure behavior" in the resident.
No assessment related to the pre-seizure activity appeared anywhere in the resident's clinical record.
The facility's own policies required comprehensive documentation of resident assessments and mandated that all physician orders be followed by licensed personnel. The Director of Nursing confirmed during interviews that she would expect assessments to be completed when residents experienced seizure-like activity.
State inspectors reviewed the resident's medical records and found a pattern of incomplete care. The patient's most recent comprehensive assessment had been marked as incomplete because the resident was "rarely/never understood" due to cognitive impairment from Alzheimer's disease.
The inspection revealed fundamental gaps in emergency medical response at the 120-bed facility. When nursing assistants identified concerning symptoms in a vulnerable resident, the licensed nurse's intervention consisted of a brief visual check followed by an attempt to use expired medication.
Staff B's decision to abandon further assessment because of her own physical condition left the resident without proper medical evaluation during a potential seizure episode. The facility's policies clearly outlined expectations for resident assessment and documentation, but those protocols were not followed.
The resident's seizure disorder required careful monitoring and immediate response to any changes in condition. Alzheimer's patients face additional risks during seizure activity due to their inability to communicate symptoms or follow safety instructions.
Federal regulations require nursing homes to ensure residents receive proper treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The failure to assess a resident during reported seizure activity directly contradicted those standards.
The inspection found that expired emergency medications remained accessible to nursing staff, creating additional safety risks. Proper medication management requires regular inventory checks and removal of expired drugs from clinical areas.
Progress notes from the incident showed that while nursing assistants properly reported their observations of pre-seizure behavior, the clinical response system failed. The registered nurse's incomplete intervention and lack of follow-up assessment left gaps in the resident's medical record and potentially compromised care.
The Director of Nursing's acknowledgment that seizure assessments should be completed highlighted the disconnect between facility expectations and actual practice. Staff B's failure to complete required assessments violated both physician orders and facility policies designed to protect vulnerable residents.
The resident remained at Careage Hills following the inspection, still dependent on staff for all activities of daily living and requiring ongoing seizure monitoring. The facility's response to future seizure activity would determine whether similar assessment failures might recur.
State inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. The finding focused specifically on the failure to assess Resident #2 during the reported seizure episode and the attempt to administer expired medication.
The inspection report did not indicate whether the facility had implemented corrective measures to prevent expired medications from remaining in clinical areas or to ensure nursing staff complete required assessments regardless of their personal physical condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careage Hills Rehabilitation and Healthcare from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
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