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 ensure that a comprehensive, person-centered care plan was developed and implemented to meet the needs and preferences of a resident with multiple diagnoses, including congestive heart failure, bilateral lower leg lymphedema, and diabetes. The resident's care plan specified that transfers should be performed using a Hoyer mechanical lift or with the assistance of two staff members, as directed by Physical Therapy and documented in the care plan. However, on the date of the incident, a CNA assisted the resident from her chair to standing without the required second staff member, contrary to the care plan instructions. During this transfer, the resident's knee buckled, resulting in a fall and subsequent injury. The resident was sent to the emergency room and diagnosed with a fracture of the right distal knee, which required surgical repair. Staff interviews confirmed that the CNA was aware of the resident's two-person transfer status but chose to proceed alone, leading to the incident.