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F0689
D

Unsafe Transfer Technique Used During Resident Assistance

Prophetstown, Illinois Survey Completed on 07-23-2025

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 certified nursing assistant (CNA) was observed pulling a resident's left arm to assist him out of a recliner, raising the arm above the level of the resident's head. The resident had a history of traumatic brain injury, quadriplegia, repeated falls, limited mobility, decreased strength, and decreased sitting and standing balance, and required assistance with ambulation and transfers. The Director of Nursing (DON) confirmed that a gait belt should be used for such transfers and that pulling a resident's arm could cause injury. The facility's policy requires safe handling during transfers to prevent or minimize injury, but this was not followed in the observed incident.

An unhandled error has occurred. Reload 🗙