Failure to Prevent Accidents and Implement Seizure Precautions
Penalty
Summary
The facility failed to implement necessary interventions to prevent injuries for two residents. In the first instance, a resident with a history of a displaced comminuted fracture of the left femur and severe cognitive impairment was observed being transported in a wheelchair without the use of footrests. The resident's feet were on the floor while being pushed by a CNA, despite facility policy and staff interviews confirming that footrests should be used during transport to prevent the resident's feet from dragging and potentially causing injury. In the second instance, a resident with epilepsy and a care plan indicating seizure precautions was found to have unpadded metal bedside rails. Observations and interviews with the resident and nursing staff confirmed that the bedside rails were not padded as required to protect the resident from injury during seizure activity. The facility's policy on seizure precautions specifies that residents should be protected from injury according to current standards of practice, including the use of padded rails.