Complaint Investigation Report

Interviews revealed that a major seizure is one that lasts about 15 minutes or longer which C1 will require a rescue medication. A rescue medication is a nasal spray called Nayzilam that helps stop the seizures. Interviews revealed that any four or more seizures lasting four minutes each will require the client to take the rescue medication.

Interviews with staff revealed there is a certain protocol the facility follows when a client has a seizure. When a client has a seizure, they will keep them on the floor and get them comfortable with blankets and pillows until their episode ends. Interviews revealed that during the time the client is on the floor, they are monitoring the time of the seizures and counting them to make sure no rescue medication is needed. Interviews revealed that typically the client will stay on the floor for at least 30 minutes before staff help them up and escort them to their bed. Interviews revealed the staff know never to let the client get up and walk on their own after a seizure. Interviews revealed on 06/09/2024, C1s family member came to pick up C1 for the day and returned later that day. Interviews revealed on 06/11/2024, staff found C1 on the floor after dinner around 7:00 pm. Staff began to do what they are trained to do, which is leave the client on the floor, clear their surroundings and make C1 as comfortable as possible and monitor their seizure. C1 had three little seizures, and no rescue medication was administered since the seizures were each less than two minutes. Interviews revealed staff waited about half an hour before they got C1 up from the floor and put them into a wheelchair, and escorted them to bed around 8:00 pm. Interviews revealed that staff changed C1’s diaper while assessing C1 from head to toe, moving all their joints and there were no signs of visible injuries or bruising. On 06/12/2024, C1s family member came to the facility around 8:30 am and they observed C1 wasn’t up yet. Interviews revealed that the lead staff arrived at the facility around 9:30 am, and they went to check on C1. Interviews with lead staff revealed that they assessed C1 to see if any bruising appeared overnight and they did not observe any visible injuries or bruising on C1.