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 staff failed to provide safe assistance during a transfer for a resident with diagnoses of difficulty walking and osteoarthritis. The resident, who had intact cognition and required assistance of one staff member with a rolling walker for transfers per physician order, was being assisted by a nursing assistant who did not use the prescribed walker. Instead, the resident was stood up facing the front of a wheelchair, holding onto its arms while the wheelchair was locked. During this process, the resident's knee buckled, causing a fall to the floor. As a result of the fall, the resident sustained a fractured right humerus and a fractured right patella, requiring transfer to the hospital for evaluation and treatment. Facility documentation and staff interviews confirmed that the wheelchair was used as a support device during the transfer, contrary to both physician orders and facility fall prevention policy, which directed the use of appropriate assistive devices such as a walker, grab bar, or railing. The incident demonstrated a failure to ensure adequate supervision and use of proper assistive devices to prevent accidents.