Failure to Implement Care-Planned Non-Skid Footwear Leading to Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from neglect by not implementing a care-planned intervention requiring proper footwear/non-skid socks to prevent falls. The facility’s abuse/neglect policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required investigation of all potential neglect incidents. The resident had a care plan for being at risk for falls that included bilateral floor mats, encouraging the resident to wear proper footwear/non-skid socks, maintaining the bed in the lowest position, providing a call bell and frequently used items within reach, a perimeter mattress, early get up, and PT/OT evaluation as needed. The resident had diagnoses including dementia, a left femur fracture, and an acute gastric ulcer with hemorrhage, and was assessed as having severe cognitive impairment, being able to be understood but rarely/never understanding others. The care plan for ADLs/mobility documented that the resident was dependent on a mechanical lift with two staff for sit-to-chair transfers and required one-person assistance to put on and take off footwear. On the night of the incident, a CNA documented that they had provided incontinence care approximately 30–40 minutes before the fall and indicated on the incident statement that the resident did not have appropriate footwear on at that time. Another staff statement from an LPN also indicated that the resident did not have appropriate footwear on. At approximately 4:10 AM, the resident was found on the floor next to the bed, face down, nude, with a small amount of feces observed, lying on or near a floor mat with the bed in the lowest position. An RN assessment initially documented no apparent injury and neurological checks within normal limits, with the resident denying pain and no pain observed in the extremities. However, a later post-fall RN assessment documented that the resident complained of right hip pain and had facial grimacing with range of motion, and an x-ray subsequently showed a right femoral fracture. There was no documented evidence that the resident was wearing non-skid socks at the time of the fall, and no documentation that the resident had refused to wear them, despite the care plan intervention to encourage proper footwear/non-skid socks.
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