Failure to Provide Ordered Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to follow physician orders for a resident with a seizure disorder by not providing bilateral padded side rails as required for seizure precautions. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was admitted and readmitted with a care plan that included interventions to protect the resident from injury during seizures. Physician orders specifically directed the use of bilateral padded side rails, and the facility's policy also listed side rail padding as a seizure precaution. Despite these orders and policies, observations on multiple occasions revealed that the resident's bedrails did not have any padding. Interviews with nursing staff and the Director of Nursing confirmed that the resident had an order for padded side rails, and that the padding was necessary to protect the resident from injury during a seizure. The facility's failure to implement these precautions constituted a deficiency in providing a safe environment and adequate supervision for the resident.