Failure to Provide Required Non-Skid Footwear for Cognitively Impaired Residents at High Fall Risk
Penalty
Summary
The facility failed to implement fall prevention interventions for several cognitively impaired residents who were identified as being at high risk for falls. During observations in the second-floor dining room, five residents were seen wearing smooth-bottomed socks rather than the required non-skid footwear, despite being out of bed and in common areas. Staff interviews confirmed that non-skid socks were available in storage, and facility policy required all residents to wear skid-proof footwear at all times when out of bed. However, the residents continued to wear inappropriate footwear for an extended period, and staff acknowledged the oversight when it was brought to their attention. Record reviews for the affected residents revealed diagnoses including dementia, major depressive disorder, altered mental status, unsteady gait, muscle weakness, and other conditions contributing to high fall risk. Each resident had care plans and fall risk assessments indicating their vulnerability to falls, with some unable to complete mental status assessments due to severe cognitive impairment. The facility's own fall prevention program required identification and implementation of interventions for residents at risk, but these measures were not followed for the residents observed.