Monument Healthcare Bountiful: Abuse Reporting Failures - UT
Monument Healthcare Bountiful reported the September incident to state authorities as required, but federal inspectors discovered the facility's abuse investigation contained no documentation of interviews with the two nursing assistants who were operating the Hoyer lift when the resident fell.
The investigation summary claimed staff interviewed the injured resident, but no record of that conversation existed either.
Resident 2 had been living at the facility with multiple complex conditions including diabetes, depression, breathing problems, and paralysis on one side of her body. She required mechanical assistance for transfers between her bed and wheelchair.
On September 22 at 7:36 AM, a restorative nurse aide alerted the charge nurse that the resident had fallen from the Hoyer lift during a routine transfer. The nurse rushed to the room and found the resident on her back, slightly turned to her right side.
The resident complained of pain in her left knee and right hip. About 30 minutes after the fall, staff discovered a "goose egg" bump on the left side of her head.
Initial assessment suggested no obvious fractures or unusual movement in her limbs and spine. But the resident continued reporting pain in her right shoulder, right hip, and left knee. She already had bruising on her right buttock that was being monitored from before the fall.
The on-call provider ordered X-rays of her right shoulder, right hip, and both knees. Staff began neurological assessments and provided ice and pain medication as needed.
Three days later, the facility's interdisciplinary team documented the fall in their review, but recorded the incident time as 8:00 AM instead of the 7:36 AM noted in nursing records.
The facility's formal abuse investigation contained another discrepancy. It stated the incident occurred on September 29 at 1:45 PM, involving two certified nursing assistants helping with the Hoyer lift transfer when "resident 2 fell out of sling upon lifting."
But the actual fall happened a full week earlier, on September 22.
Federal regulations require nursing homes to thoroughly investigate all allegations of neglect and abuse. The investigation must include interviews with relevant staff members and, when possible, the affected resident.
Monument Healthcare's investigation fell short on multiple fronts.
When federal inspectors interviewed the Director of Nursing on November 5, she acknowledged conducting staff interviews during the investigation. She said she inspected both the sling and the Hoyer lift equipment, then provided additional training to every nursing assistant on proper Hoyer use.
The training emphasized checking the sling for damage before each use and ensuring proper resident placement.
But when inspectors asked to review the interview documentation, the Director of Nursing couldn't produce it.
She told inspectors she "would have to ask the previous Administrator where the interviews for the staff and resident were located."
The Director of Nursing admitted "it was not evident that they investigated the incident for possible neglect" and confirmed "the investigation documentation did not contain copies of the interviews that were completed."
This documentation gap is significant because Hoyer lift incidents can result from equipment failure, improper sling placement, inadequate staff training, or rushed transfers. Without interviewing the two nursing assistants who were present, investigators cannot determine whether the fall resulted from neglect.
The missing resident interview is equally problematic. Residents who experience falls may have important information about what happened, including whether they felt unsafe during the transfer or noticed problems with the equipment.
Hoyer lifts are mechanical devices designed to safely transfer residents who cannot move independently. They use a fabric sling that goes under the resident's body, connected to a hydraulic or electric lift system. Proper operation requires two staff members and careful attention to sling placement and equipment condition.
When these lifts fail or are used improperly, residents can suffer serious injuries including fractures, head trauma, and internal injuries. The mechanical nature of the equipment means falls often occur from significant heights, increasing injury risk.
Monument Healthcare reported the incident to the State Survey Agency as required by federal regulations. Nursing homes must report suspected abuse or neglect within 24 hours and complete investigations within five working days.
But reporting the incident is only the first step. The investigation must be thorough enough to determine whether neglect occurred and what corrective actions are needed.
In this case, the facility's investigation raised more questions than it answered. The conflicting dates in different documents suggest poor record-keeping throughout the process.
The September 22 nursing notes provide the most detailed account of the immediate response. The charge nurse's assessment appears thorough, checking for fractures and unusual movement while documenting the resident's specific complaints.
The decision to order X-rays and begin neurological monitoring suggests appropriate medical response to the fall.
However, the investigation's failure to document staff interviews leaves crucial questions unanswered. Were the nursing assistants properly trained on Hoyer lift operation? Did they follow established procedures? Was the sling in good condition and properly positioned?
Without this information, the facility cannot demonstrate that it ruled out neglect as required by federal regulations.
The Director of Nursing's acknowledgment that she conducted training with all nursing assistants after the incident suggests the facility recognized potential problems with Hoyer lift procedures. But the investigation should have documented what specific issues the training addressed.
The missing documentation also prevents outside reviewers from evaluating whether the facility's corrective actions were appropriate and sufficient.
Federal inspectors classified this as a violation with minimal harm or potential for actual harm. But the resident did sustain fractures requiring X-rays and ongoing medical monitoring.
The facility's investigation failures mean questions about potential neglect in this case may never be fully answered, despite the serious injuries the resident suffered during what should have been a routine transfer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monument Healthcare Bountiful from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Monument Healthcare Bountiful in Bountiful, UT was cited for abuse-related violations during a health inspection on November 6, 2025.
The investigation summary claimed staff interviewed the injured resident, but no record of that conversation existed either.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.