Failure to Ensure Ordered Fall-Prevention Footwear for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a high fall‑risk resident consistently had ordered fall interventions, specifically gripper/non‑skid socks, in place. The resident had multiple significant diagnoses, including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss. A Morse Falls assessment identified the resident as high risk for falls, and the care plan documented fall‑risk related to deconditioning and gait/balance problems, with interventions such as keeping the call light and frequently used items within reach, ensuring appropriate footwear, use of gripper socks when not wearing proper fitting shoes, therapy evaluation, and a toileting plan before and after meals and at bedtime. The admission MDS showed intact cognition and no prior falls at admission. Progress notes and fall scene investigations documented multiple falls where the resident was not wearing appropriate footwear as care planned. On one occasion, the resident stood from bed wearing only socks, reached toward the nightstand, stepped forward, and lost balance, leading to a fall; he was then educated on proper footwear and call light use. A subsequent fall occurred when the resident again was not wearing gripper socks but only regular socks, and the interdisciplinary team identified the need for gripper socks when not in proper shoes and for frequently used items to be closer. Another fall occurred when the resident was found on the floor outside the bathroom after walking back from the bathroom in socks, with a bruise to the left thigh noted; the fall scene report indicated he had been given a laxative and was wearing socks at the time. Although physician orders were written for gripper/non‑skid socks to be worn when not in proper fitting shoes and to check each shift for proper placement, and later for non‑skid socks while out of bed, the DON confirmed the resident did not have gripper socks on as ordered when he fell and that there was no documentation that he removed or changed them himself. The facility’s fall assessment policy was in place, but the ordered and care‑planned fall interventions were not consistently implemented for this resident.
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