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

A deficiency occurred when the facility failed to develop and implement a comprehensive care plan that included a resident's transfer status. The resident in question had diagnoses of hemiplegia, hemiparesis affecting the left non-dominant side, and muscle weakness, and was identified as dependent for transfers according to the annual MDS. The resident's care plan noted deficits in activities of daily living and a risk for falls, but did not specify the use of a mechanical lift or any transfer status. There was also no physician order for transfer status or use of a mechanical lift documented in the record. An incident occurred when a nurse aide transferred the resident into bed using a mechanical lift without a second staff member present, resulting in the resident falling to the floor. The Director of Nursing confirmed that the resident had required a mechanical lift since admission and acknowledged that the care plan should have included this information. Although the nurse aide assignment sheet reportedly directed use of a mechanical lift, the facility was unable to provide a copy. Review of facility policy indicated that care plans should be comprehensive and individualized to meet residents' needs.