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F0689
D

Failure to Use Proper Transfer Technique Resulting in Resident Injury

Emmetsburg, Iowa Survey Completed on 05-22-2025

Penalty

No penalty information released
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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

A deficiency occurred when a certified nursing assistant (CNA) failed to use appropriate transfer techniques for a resident who required partial to moderate assistance with mobility due to weakness and cancer. The resident, who had no cognitive impairment and was care planned to have two staff assist with mobility and to avoid grabbing his arms due to fragile skin, sustained multiple skin tears on his right forearm after the CNA grabbed his wrist instead of using a gait belt during a transfer. The skin tears measured 4 cm by 1 cm, 2.5 cm by 1 cm, and 2 cm by 1 cm, with blood noted from each area. Documentation confirmed the incident and the CNA's violation of facility protocol.

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