Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident identified as high risk for falls. According to the facility's Fall Reduction policy, residents with a high fall risk should have individualized interventions documented and implemented in their care plan. The resident in question had multiple diagnoses, including unsteadiness on feet, dementia, and a history of repeated falls. The care plan specifically required the use of gripper socks as an intervention to reduce fall risk. Despite these documented interventions, observations on two separate occasions showed the resident seated in common areas without gripper socks or any foot coverings, with bare feet on the floor. Staff present at the time confirmed that the resident was supposed to wear gripper socks at all times due to the high risk of falls and previous incidents. The lack of adherence to the care plan's fall prevention measures constituted a failure to provide adequate supervision and implement necessary precautions.