F0600

D

Failure to Follow Two-Person Transfer Care Plan Resulting in Resident Injury

Kings Park, New York Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to protect a resident from neglect by not following the comprehensive care plan and current transfer instructions. The resident had diagnoses including UTI, atrial fibrillation, hypertension, and COPD, and an MDS assessment documented intact cognition and a need for assistance of two or more helpers for transfers from chair to bed and toilet. The comprehensive care plan and kiosk nursing instructions, updated in mid-October, specified that the resident required two-plus person physical assistance for transfers. Despite this, on the evening in question, a CNA attempted to transfer the resident from a wheelchair to a bed using only a one-person assist, contrary to the documented plan of care and kiosk instructions.

During the transfer, the resident’s legs became weak and the CNA lowered the resident to the floor, resulting in removal of a scab and an open area on the left knee measuring 3 cm by 3 cm by 0 cm, which required cleansing with normal saline, application of Neosporin, and a dry protective dressing. The CNA later stated they did not check the kiosk nursing instructions for the resident’s current transfer status prior to the transfer and acknowledged they usually do not check if they are familiar with the residents, relying instead on the resident’s prior status before readmission. An RN found the resident on the floor lying on the left side, with the left knee injury but no reported pain, discomfort, or head injury. The DON stated the expectation that the CNA should have checked the kiosk for the resident’s current transfer status at the beginning of the shift before providing care, consistent with the facility’s abuse and neglect policy, which defines neglect to include failure to follow the care plan.