Failure to Ensure Appropriate Footwear Resulting in Fall and Intracranial Hemorrhage
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for falls wore appropriate footwear to prevent accidents. The resident was an older adult with diagnoses including pulmonary embolism with acute cor pulmonale, essential hypertension, coronary artery disease with stent, dementia, and other conditions. The resident’s MDS documented a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan, initiated in January 2026 and revised in February 2026, specifically included an intervention to ensure the resident wore appropriate footwear that provided stability and good traction when ambulating, mobilizing in a wheelchair, and during transfers. On the day of the incident, the resident was ambulating with a walker in a supervised area near the nurses’ station, walking toward the dining room. Staff statements and nursing documentation indicate that the resident abruptly stood up or was walking with the walker, lost balance, and fell backwards. The LPN on duty reported hearing the walker, then seeing the resident on the floor, and documented that the resident appeared to have hit her head. The LPN and other staff confirmed that the resident was wearing slide shoes at the time of the fall, described as open-toed, backless footwear with a strap across the top of the foot. The LPN acknowledged that slides were the resident’s preferred footwear but stated that, honestly, this was not appropriate footwear for the resident. Following the fall, the resident, who was on blood thinners (Eliquis), was sent to the hospital for evaluation. Hospital records document that the resident presented after a mechanical fall with head impact, reporting headache, neck pain, and wrist bruising. Imaging studies, including CT and MRI of the brain, identified a tiny left frontal, parietal, temporal, and occipital subdural hematoma and a small focus of subarachnoid hemorrhage in the left posterior frontal lobe. The nurse practitioner and restorative nurse both indicated that proper footwear for a resident of this age and condition should include closed-toe/heel shoes or non-skid socks with grip, and that slide footwear was not appropriate. The facility’s fall guidelines required incidents and accidents to be identified, reported, investigated, and used for QAPI trending, but the failure to ensure the resident wore appropriate, care-planned footwear directly preceded the fall and resulting intracranial bleeding.
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