F0689

G

Failure to Follow Fall Care Plan and Ensure Appropriate Footwear Resulting in Major Injury

Arvada, Colorado Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident at high risk for falls received adequate supervision and appropriate footwear as care planned, resulting in a fall with major injury. The resident was an older adult with osteoarthritis, dementia, Alzheimer’s disease, repeated falls, severe cognitive impairment (BIMS score 3/15), and a documented history of falls. The resident’s fall care plan, initiated months earlier and revised prior to the incident, identified her as a high fall risk related to deconditioning, gait and balance problems, incontinence, poor communication and comprehension, unawareness of safety needs, and prior falls. Among the listed interventions was the requirement to anticipate and meet her needs and to encourage the resident to wear appropriate footwear/non-skid socks when ambulating or mobilizing in a wheelchair.

On the date of the incident, the resident sustained an unwitnessed fall and was later found lying on the floor of another resident’s room. Nursing documentation and the IDT note recorded that the resident’s shoes or slippers were on the bed in that room, positioned neatly, and that she was wearing regular socks rather than the care-planned non-skid/anti-slip socks at the time of the fall. Staff interviews corroborated that the resident did not have non-skid socks on; a CNA specifically recalled the resident wearing regular black socks. The care plan intervention requiring non-skid socks had been in place since 7/19/23, but the resident was not wearing them when she was discovered on the floor. The IDT note identified the root cause of the fall as a change in condition with altered mental status, but the documentation and DON interview confirmed that the anti-slip sock intervention was not in use at the time of the fall.

Following the fall, multiple staff documented that the resident was unable to walk and required a wheelchair, which was a change from her prior status of independent ambulation without assistive devices. Nursing notes described the resident complaining of pain in her left arm and left leg, difficulty standing on her left leg, and increased confusion compared to baseline. Neurological checks were initiated, and a STAT X-ray was ordered and read as negative, but the resident continued to show pain, difficulty bearing weight, and altered mentation. Two days after the fall, due to ongoing increased confusion, pain, and inability to walk, the resident was sent to the hospital, where she was diagnosed with a subdural hematoma and a closed left hip fracture requiring surgical repair. The deficiency centers on the facility’s failure to follow the established fall care plan intervention for appropriate non-skid footwear and to provide adequate supervision to prevent accidents for this high fall risk resident.

Staff interviews further highlighted gaps in awareness and implementation of fall risk interventions. One CNA stated that the resident was not a fall risk and was independent with ambulation, which conflicted with the care plan identifying her as a high fall risk with specific fall interventions. Another CNA described assuming the resident had gone on an outing when she did not see her on the secured unit and only began searching after the nurse could not confirm the resident’s whereabouts, at which point the resident was found on the floor in another room. The memory care director reported that the resident often wandered into that other resident’s room and was found there on her left side, complaining of pain when staff attempted to assist her. These observations and statements demonstrate that the resident’s known fall risk status and care-planned interventions, including appropriate footwear and supervision, were not consistently recognized or implemented at the time of the fall.