Failure to Ensure Appropriate Footwear for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. A female resident with diagnoses including heart failure, chronic respiratory failure, muscle wasting and atrophy, dementia, lack of coordination, and a history of falling was readmitted to the facility and assessed as having moderate cognitive impairment (BIMS 12). The MDS documented that she used a wheelchair for mobility, could independently propel herself in the wheelchair, and required substantial/maximal assistance with transfers, lower body dressing, and putting on/taking off footwear. Her care plan, revised earlier in the month, identified her as at risk for falls with actual falls on four prior dates, including one fall that resulted in facial bruising and a hematoma requiring hospital evaluation. Incident reports for these falls did not identify improper footwear as a pre-disposing factor. On the survey date, observations showed the resident self-propelled her wheelchair into the dining room using her feet while wearing red and green socks without an anti-slip surface, and later sitting in the dining room playing bingo with the same non-slip-resistant socks, with one sock slipped down beneath her heel. Multiple staff interviews, including with an RN, CNAs, an LVN, the ADON, and the Administrator, confirmed that the resident was considered a major/significant fall risk with recent fall injury and lack of safety awareness, and that fall interventions for at-risk residents included wearing anti-slip socks or shoes. Staff also stated that this resident should have had anti-slip footwear on to prevent falls and that not having appropriate footwear in the dining room could result in additional falls and injury. The facility’s fall management policy stated it was the facility’s policy to provide an environment as free of accident hazards as possible and to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs.
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