§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
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Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding seizures and an implanted device to control seizures for one of one resident reviewed (Resident 1).
Findings Include:
Clinical record review for Resident 1 revealed the resident was admitted to the facility on June 23, 2025.
Review of Resident 1's diagnoses list revealed the resident was listed with a conversion disorder (neurological symptom disorder) with seizures (sudden surge of abnormal electrical activity in the brain that causes temporary changes in behavior, awareness) or convulsions (rapid, involuntary muscle contractions causing uncontrollable shaking and body spasms), since admission to the facility.
Review of documentation from the resident's hospital admission prior to admission to the facility revealed an Epilepsy Monitory Unit discharge summary dated June 17, 2025, which noted the resident had a long-standing history of seizure/seizure like activity first noted back in the year 2012. It noted the resident had a VNS device (Vagus Nerve Stimulation an implanted device used to send mild electrical impulses to the brain via the vagus nerve in your neck at programmed intervals which can also be activated manual if a patient senses a seizure starting by swiping a magnet over the chest device to deliver an extra burst of stimulation to help stop or shorten the seizure), placed June 18, 2012, and changed in March 31, 2021.
A progress note dated January 22, 2026, at 9:50 AM for Resident 1 noted facility staff were called to the resident's room for the resident experiencing back-to-back seizures with a time length of 45 seconds to five minutes. A follow up note 10:27 AM noted the resident was sent to the emergency room for an evaluation. There was no evidence of any documentation as to whether the resident's VNS device was utilized during the incident.
Review of a neurology consult for Resident 1 dated February 24, 2026, noted the resident's "magnet output increased,and "autostim threshold decreased," in reference to the resident's VNS device. The consult also noted the residents "battery is at 25-50% - next range is 12.5-25% - would then need to get established with neurosurgery for battery replacement."
Further review of Resident 1's clinical record revealed the resident was ordered routine and as needed medication for seizures on January 22, and January 24, 2026, and that the resident continues to receive routine and as needed medication for seizures.
Review of Resident 1's May medication administration record revealed the resident received as needed doses of seizure medication on May 1, 3, 4, 5, 6, 15, 2026. There was no evidence to indicate if the resident's VNS device was utilized during any of these instances.
Observation and interview of Resident 1 on May 20, 2026, at 1:29 PM indicated the resident stated a long history of seizure activity and that she had a device implanted in her chest that she indicated is going to need a battery replacement. Resident 1 pointed out a watch like band (magnet) on her right wrist which she indicated was to be used for the device when she was having a seizure.
Review of Resident 1's active plan of care revealed the resident's seizure disorder was not addressed on the plan of care until May 20, 2026, (date of survey), despite the resident being admitted to the facility in June 2025 with the disorder and the presence of an implanted VNS device, or after having seizure like activity in January 2026, with the addition of seizure medication. The plan of care initiated on May 20, 2026, also did not include any information regarding the resident's VNS device (location of magnet, when to utilize it, or how staff are to utilize the device).
The above findings were reviewed with the NHA and DON on May 20, 2026, at 3:43 PM.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 06/05/2026
1. Resident 1's comprehensive person-centered care plan was reviewed and revised, to include interventions related to seizure disorder management and the resident's implanted Vagus Nerve Stimulator (VNS) device.
2. An audit of all current residents with diagnoses related to seizure disorders, epilepsy, convulsions, neurological disorders, and/or implanted seizure-related devices was completed by the Director of Nursing/designee to determine whether comprehensive person-centered care plans were in place and accurately reflected individualized interventions.
3. The facility revised its care planning process to ensure residents with seizure disorders and implanted devices receive individualized comprehensive care plans upon admission, readmission, change in condition, or receipt of new physician orders.
4. The interdisciplinary team (IDT) was educated regarding requirements for comprehensive person-centered care planning related to seizure disorders and implanted devices, review of hospital discharge documentation, specialty consults, and physician recommendations to ensure all pertinent information is incorporated into the resident's care plan. Licensed nursing staff were educated regarding Resident 1's seizure management interventions, including proper use and documentation of the VNS device and magnet.
5. The Director of Nursing/designee will conduct weekly audits for four weeks, then monthly audits for two months, of residents with seizure disorders and/or implanted neurological devices to ensure Comprehensive care plans and interventions are in place, Audit results will be reviewed at QAPI
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