Failure to Implement Seizure Precautions for Resident
Penalty
Summary
The facility failed to implement appropriate seizure precautions for a resident with a history of syncope, repeated falls, and a recent seizure episode. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, experienced an unwitnessed fall and a witnessed seizure within the same day. Medical orders and care plans specified the use of two, one-half padded side rails as a seizure precaution, and interventions included ensuring proper body alignment and padding of side rails as needed. Upon observation, only one side rail was partially padded with a pool noodle, leaving parts of the rail exposed, while the other rail was not padded at all. Interviews with staff revealed uncertainty regarding the correct application of padding for seizure precautions, and the Director of Nursing confirmed that maintenance staff were unfamiliar with the installation of side rail pads due to the infrequent use of seizure precautions in the facility. The facility's policy on seizure precautions did not provide instructions for side rail pad application.