Failure to Implement Seizure and Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident with a history of seizures and on anticoagulant therapy. The resident had multiple diagnoses, including epileptic seizures, peripheral vascular disease, chronic kidney disease, muscle weakness, difficulty walking, osteoarthritis, major depression, and a history of subarachnoid hemorrhage with residual hemiplegia and hemiparesis. The resident was prescribed Eliquis and Keppra, but there were repeated refusals of the seizure medication Keppra over several days. There was no documentation that these refusals were reported to the physician or nurse practitioner, nor were new interventions initiated to address the increased seizure risk. On the day of the incident, the resident was found on the floor next to the bed after experiencing a seizure, with significant bleeding from a head wound. The bed was not in the low position, and no fall mats or side rails were in use. Staff interviews confirmed that the bed was not kept in the low position prior to the fall, and that refusals of seizure medication were not routinely reported to medical providers. The facility also lacked a specific policy for seizure precautions. As a result of the fall, the resident sustained a six-centimeter scalp laceration requiring evacuation of a hematoma and sutures, as well as a subdural hematoma.