Maples Benzie County Medical Care

she left to go retrieve a pair of gripper socks from the linen storage room but realized there were no socks stocked.

When asked the usual protocol if the unit were to run out of supplies, CNA B stated staff was supposed to restock the supplies from either laundry or borrow from a different unit. CNA B admitted she was too busy at the time and did not locate a pair of gripper socks for R3 to wear prior to leaving him in bed.

When asked if R3 was care planned to wear gripper socks while in bed, CNA stated, He is now. I'm unsure if he was at the time [of the fall].Review of a Witness Statement written by CNA C on 7/25/25 revealed the following questions and answers: What were you doing prior to the incident? Getting slip socks [grip socks] for him and there was none on the unit.

What did you see concerning the alleged incident? [R3] did not have any slip socks [grip socks] on or in his room so I went to get some and there was none on the unit.On 8/12/25 at 12:30 PM, a telephone interview was conducted with CNA C regarding R3's fall on 7/25/25. CNA C recollected she responded to R3's sounding bed alarm and located R3 in the bathroom upon entrance into the room. CNA C stated, I noticed he didn't have any gripper socks on. so I told him I was going to grab a pair from the storage room. He's usually fine in the bathroom alone. CNA C reported when she was unable to find gripper socks in the storage closet, she left the unit to locate a pair.

Upon return to the unit, CNA C saw Licensed Practical Nurse (LPN) D assessing R3 who was on the floor after an apparent fall. CNA C stated, I don't understand why anybody would put him in regular socks.he shouldn't have had those socks in his room to begin with.Review of an Unwitnessed Fall Report written by LPN D on 7/28/25, read, in part: Heard a loud bang noise. went to resident room, He [R3] was laying on the floor on his right side facing towards bathroom.

Head was propped against wall. quarter size hematoma visible to forehead above right eye.

Intervention to not leave [R3] unattended while in bathroom and wear non-skid socks of shoes at all times when out of bed.On 8/12/25 at 12:43 PM, a telephone interview was conducted with LPN D regarding R3's fall on 7/25/25. LPN D recalled R3 was left unattended in the bathroom and fell after attempting to self-transfer. LPN D admitted , He's [R3] pretty impulsive.

When asked if R3 was wearing gripper socks at the time of the fall, LPN D stated, No, just normal socks.

When asked if R3 was care planned to wear gripper socks, LPN D replied, I would assume he's care planned for gripper socks.On 8/13/25 at 10:37 AM, an interview was conducted with Assistant Director of Nursing (ADON) G regarding any injuries R3 sustained because of the fall on 7/25/25. ADON G stated R3 was transferred to an acute care hospital for further testing due to reports of increased right hip pain and eventually readmitted to the facility.On 8/13/25 at 10:54 AM, an interview was conducted with the Director of Nursing (DON) regarding care plan implementation expectations.

The DON confirmed R3 should have been wearing gripper socks per his plan of care.

The DON stated if gripper socks were not available on the unit, it is expected for personnel to locate additional pairs within the facility.

Review of the facility policy titled, Fall Risk Protocol: High Risk, dated 5/18/22, read, in part: .Protocol: implement interventions.that address unique risk factors: medications, psychological, cognitive status, recent change in function status, or root causes of recent fall(s).

Review of the facility policy titled, Adding Interventions to the Plan of Care for Events, dated 5/15/17, read, in part:Purpose: the purpose of the intervention is to assure that we are doing everything possible to prevent a similar event from occurring again and to keep our residents safe .

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