Failure to Provide Adequate Supervision and Fall Prevention for Resident with Seizure Disorder
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with a known seizure disorder. The resident, who had a history of seizures and multiple medical diagnoses including epilepsy, experienced several falls while in the facility. Despite being alert and oriented, the resident was dependent on staff for supervision or assistance with ambulation and had a documented history of falls, many of which were associated with seizure activity or occurred after smoking. The care plan for the resident included interventions such as reviewing the smoking policy, encouraging the use of non-skid shoes, and having the resident sit or lie down after smoking. However, these interventions were not consistently implemented or communicated to staff. Multiple staff members, including CNAs and an RN, were unaware of specific interventions to prevent injury prior to falls, particularly those related to seizures. Observations confirmed that the resident was not assisted or encouraged to sit or lie down after smoking, despite this being an identified intervention. Interviews with staff revealed a lack of awareness and understanding of the resident's fall and seizure risk interventions. Staff responses indicated that their knowledge was limited to general safety measures, such as keeping the environment free of clutter and monitoring the resident, rather than specific actions to prevent falls related to seizures. The facility's failure to ensure staff were informed and interventions were consistently applied contributed to the ongoing risk of falls and injury for the resident.