Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision to prevent falls for a resident with a history of muscle weakness, difficulty walking, and previous falls. The resident's care plan directed staff to keep personal items and assistive devices within reach. On the date of the incident, a CNA assisted the resident in transferring to a couch in the common area. After the transfer, the CNA placed the resident's wheelchair nearby, but a nurse instructed the CNA to remove the wheelchair and place it behind the couch to prevent the resident from attempting to self-transfer. Following the removal of the wheelchair, the resident attempted to self-transfer, lost balance, and fell, resulting in a head injury. The incident and accident report documented that the resident was 5-7 feet away from a transfer area at the time of the fall. Statements from two CNAs indicated that the removal of the wheelchair contributed to the fall. The resident sustained a goose egg on the right side of the head and was sent to the hospital for further evaluation.