Failure to Implement Fall-Prevention Footwear Intervention
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement an existing At Risk for Fall care plan for one resident. The resident’s admission record showed diagnoses including osteoarthritis, schizophrenia, anxiety, chondrocostal junction syndrome, and gait and mobility abnormalities. An MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for moderate assistance with toileting, showering, and dressing, and supervision for walking. The resident’s At Risk for Fall care plan, initiated 4/10/2025, included an intervention to ensure the resident wore appropriate footwear when ambulating. A Fall Risk Evaluation dated 10/6/2025 indicated the resident was at risk for a fall. On 10/9/2025, a Change of Condition Note documented that the resident was found sitting on the floor by the bed and reported losing balance and falling while returning from the restroom to the bed. A Post Fall Evaluation from the same date indicated the resident was barefoot at the time of the fall. During an interview and concurrent record review with an RN on 1/27/2026, the resident’s progress notes from 10/2025 and the At Risk for Fall care plan were reviewed, and the progress notes lacked documentation that the resident’s footwear was monitored. The RN stated that, because there was no documented monitoring of footwear, the intervention could not be verified as implemented and that this lack of effective implementation of the care plan placed the resident at increased risk for a fall. The facility’s Comprehensive Person-Centered Care Planning policy required development and implementation of a comprehensive care plan with measurable objectives and timeframes to meet identified needs.
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