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

Facility staff failed to follow acceptable standards of practice when transferring a resident after a fall. Video evidence showed that two CNAs lifted a resident from the floor to a wheelchair by pulling under the resident's arms, without the use of a gait belt, despite facility policy requiring the use of appropriate lifting techniques and devices. Both CNAs later confirmed in interviews that a gait belt should have been used during the transfer, and the Director of Nursing and Executive Director also stated that staff are expected to use a gait belt in such situations. The resident involved had a history of late onset Alzheimer's dementia with behavioral disturbances, short term memory loss, a recent right femur fracture with weight bearing as tolerated, and muscle weakness. The incident was not documented in the resident's progress notes, and there was no evidence of a fall assessment or post-fall follow-up. The facility's policies require documentation and appropriate notification following such events, but these procedures were not followed in this case.