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 resident was free from neglect, resulting in actual harm. A resident with a history of cerebral infarction, right above-the-knee amputation, and diabetes mellitus type II required assistance from two staff members for activities of daily living (ADLs), as documented in the care plan and Kardex. During an incident, a nurse aide provided incontinence care alone, contrary to the resident's care plan, which specified a two-person assist for all ADLs. The aide was unaware that incontinence care was considered an ADL and did not recognize the need for a second staff member during the care. As a result of this failure to follow the established plan of care, the resident fell from the bed while being assisted by only one staff member, sustaining an acute right-sided intertrochanteric hip fracture. The resident experienced pain and required transfer to the hospital for evaluation and treatment. The incident was witnessed and documented, and the nurse aide involved confirmed a lack of understanding regarding the required level of assistance for the resident during ADL care.