Failure to Ensure Use of Non-Skid Socks and Proper Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls was wearing non-skid socks as required by the care plan. The resident, who had a documented high fall risk score and a care plan intervention specifying the use of non-skid socks, was found not wearing them at the time of an unwitnessed fall. Staff interviews confirmed that the non-skid socks had been removed prior to the incident, and the resident was not wearing them when found on the floor. The facility's policy required the use of proper footwear to prevent falls, but this was not followed in the resident's case. Additionally, the facility did not follow its in-service protocol on falls, which required an RN to assess any resident found on the floor before moving them. After the resident was found on the floor complaining of left hip pain, an LVN and a CNA transferred the resident to a wheelchair and then to bed without waiting for the RN's assessment. The RN supervisor arrived shortly after and, upon assessment, suspected a hip fracture and sent the resident to the hospital. Staff interviews confirmed awareness of the protocol but acknowledged it was not followed in this instance.