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 high fall risk resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's dementia, osteoporosis, and a history of falls, was admitted for short-term rehabilitation. The resident required supervision and assistance for mobility and was identified as needing assistance at all times. On the evening of the incident, a CNA found the resident on the floor with her leg turned inward, a sign that may indicate the need for immediate medical attention. The LPN and two CNAs assisted the resident back into bed without a documented full post-fall or neurological assessment. The nurse noted the resident had limited movement in one leg and reported pain, but only provided a pillow for comfort initially. There was no documentation of a comprehensive assessment following the fall. Over the next several hours, nursing staff made multiple unsuccessful attempts to contact the on-call provider. Pain medication was not administered until more than three hours after the fall, and EMS was not contacted during this period. The LPN did not call 911, believing a provider order was required, despite the resident's visible injury. The resident was ultimately transported to the hospital over four hours after the fall, following a delayed response from the on-call provider. Interviews with staff and the resident's family confirmed concerns about the delay in assessment, pain management, and emergency intervention.