SSM Health DePaul Anna House: Lift Injury Violation - MO
The incident, which left the resident with a swollen knee requiring a doctor's call and an x-ray, was cited as causing actual harm during a complaint inspection completed October 17, 2025.
CNA C had been assigned to the resident and needed to change their brief. CNA B was the staff member CNA C asked for help, but CNA B was talking to RN A at the time. CNA C didn't wait. They used the sit-to-stand lift alone.
The resident began resisting mid-transfer, moving around, trying to pull their arms free from the sling. CNA C lowered the resident toward the base of the lift. The resident's leg bent. CNA C screamed.
CNA B and RN A were eating lunch at the nurse's station when they heard it. CNA B entered the room and found the resident hanging from the lift, knees on the base, arms swinging. "He/she looked like a string puppet," CNA B told inspectors. CNA C was standing next to the lift.
CNA B stepped back out and got RN A. Together, they removed the resident from the sling, placed a Hoyer pad underneath them, and transferred them to bed. The resident's knee was swollen. RN A called the doctor, who ordered an x-ray.
Every staff member interviewed said the same thing: lift transfers require two people. The certified medication technician said it. CNA E said it. CNA C said it. The interim director of nursing said it. The administrator said it. Nobody disputed what the policy was.
What they disputed, or at least couldn't fully account for, was why nothing in the resident's room made the transfer requirements clear. CNA C told inspectors there were no signs posted to identify the resident's transfer status. CNA C said they had used the sit-to-stand and the Hoyer lift interchangeably on this resident before. The resident's care plan, the administrator later acknowledged, "could be interpreted a couple different ways."
The interim director of nursing, who had been at the facility ten months, said the resident's care plan should have been updated. The resident had been a Hoyer lift when she started. At some point the sit-to-stand had been used, then stopped being safe because the resident kept moving their feet. That information lived in a shower book, in shift reports, in the knowledge of individual nurses. It was not on the wall of the resident's room.
CNA C told inspectors that CNA B had simply forgotten about the request for help. "If he/she could do things over, he/she would wait for assistance," CNA C said.
CNA B's account was different. CNA B said CNA C never actually asked for help before starting the transfer.
The administrator told inspectors that CNA C was terminated after the incident. He said he in-serviced staff immediately on lift policies and the two-person requirement, and that staff reevaluated all residents to confirm they were using the proper sling. He also acknowledged the facility does not document when shift report is given, which is the primary mechanism staff are supposed to use to learn a resident's transfer status.
The resident, who had a history of knee pain, did not complain of pain during the Hoyer transfer that followed the incident. Their knee was swollen anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ssm Health Depaul Hospital - Anna House from 2025-10-17 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 24, 2026 · Our methodology
SSM HEALTH DEPAUL HOSPITAL - ANNA HOUSE in BRIDGETON, MO was cited for violations during a health inspection on October 17, 2025.
CNA C had been assigned to the resident and needed to change their brief.
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.