Penalty

Fine: $13,520

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

Staff failed to follow the resident's Kardex instructions requiring two-person assistance for bed mobility and toileting, resulting in a fall. On the day of the incident, a CNA was providing incontinent care to a resident with hemiplegia and hemiparesis following a cerebral infarction, who was documented as needing extensive two-person assistance for both bed mobility and toileting. The CNA attempted to turn the resident alone, during which the resident reached for the over-bed table and fell from the bed. This incident was confirmed by interviews with the CNA, other staff, the DON, and the Administrator, as well as a review of the Kardex and MDS documentation, all of which indicated the requirement for two-person assistance. As a result of the fall, the resident sustained a skin tear to the buttocks, facial swelling, bruising, and a maxillary hematoma, which led to increased pain and a new order for tramadol, an opioid analgesic. Prior to the fall, the resident had only required minimal pain management. The facility's policy required a safe environment and adherence to care plans, but staff did not follow the documented care instructions, directly resulting in the resident's injuries.