Failure to Maintain Safety Interventions for Residents with Involuntary Movements
Penalty
Summary
The facility failed to implement safety interventions for two residents with significant cognitive and neurological impairments, resulting in one resident being struck in the face by another's involuntary movements. One resident, diagnosed with Alzheimer's disease, non-traumatic brain dysfunction, and severe cognitive impairment, was seated near the nurses' station in a wheelchair. Another resident, with Parkinson's disease, dementia, legal blindness, and an extrapyramidal movement disorder, also in a wheelchair, was seated next to the first resident. The second resident exhibited uncontrollable arm, head, and hand movements due to his medical condition. Staff interviews and records confirmed that the second resident's involuntary arm movement caused his hand to strike the first resident's face. Both residents were assessed and transported to the emergency room, returning the same day without injury. Staff interviews revealed that the second resident had a known history of involuntary, spastic body movements since admission, and interventions were in place to keep him seated at least three feet away from others to prevent accidental contact. However, on the day of the incident, staff failed to maintain this separation, and the two residents were placed next to each other by the nurses' station. Multiple staff members acknowledged awareness of the second resident's movement disorder and the need to keep him apart from others, but the intervention was not followed, leading to the incident.