F0689

D

Failure to Follow Transfer Care Plan Resulting in Resident Fall and Knee Laceration

Philadelphia, Pennsylvania Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow the resident’s care plan for transfers, resulting in a fall and injury. Facility policy on fall prevention and ADL/mobility requires that care be provided according to the resident’s individualized care plan and that appropriate interventions be implemented and communicated to reduce fall risk. The resident’s comprehensive care plan, revised in early September 2023, documented an ADL care deficit related to decreased activity, wound, back pain, and a prior CVA, and specified that the resident required use of a mechanical lift with two staff members for all transfers. The resident had a diagnosis of Parkinson’s disease and a BIMS score of 14, indicating cognitive intactness.

On the evening of February 16, 2026, contrary to the care plan, a CNA assisted the resident to stand using a walker and attempted to ambulate the resident from a recliner chair to the bed without using the mechanical lift or a second staff member. According to the CNA’s statement, the resident initially walked well until the left knee gave out, causing the resident to fall; the CNA reported obtaining a firm grip and slowly assisting the resident to the floor. Nursing notes documented that the resident was found sitting on the floor with a bleeding left knee and a skin tear, initially described as approximately 6 cm by 6 cm, and later hospital records described an approximately 8 cm by 8 cm avulsion laceration of the left knee with serosanguineous drainage and a skin flap with dusky discoloration. The facility’s investigation and counseling record for the CNA confirmed that the care plan for a two-person assist transfer was not followed and that this failure led to the resident losing balance and being lowered to the floor, resulting in the left knee skin tear.