Ssm Health Depaul Hospital - Anna House
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
CNA C should not have transferred the resident by him/herself. During an interview on 10/16/25 at 12:45 P.M., Certified Medication Technician (CMT) D said the Hoyer and Sara lift require two people for transfers.
During an interview on 10/16/25 at 12:55 P.M., CNA E said there must be a second person during a lift transfer. They are supposed to get shift report from the previous shift about the residents' transfer status.
Additionally, the transfer status was in the residents' chart. During an interview on 10/16/25 at 1:07 P.M., CNA C said he/she was assigned to the resident. He/She asked CNA B to help him/her transfer the resident. CNA B was talking to RN A. CNA C used the sit to stand lift to change the resident's brief. The resident was on the lift and started resisting the transfer. The resident moved around and tried to remove his/her arms from the sling. CNA C lowered the resident to the base of the lift. The resident's leg was bent.
CNA C screamed for help. CNA B entered the resident's room, then stepped out to get RN A. The resident was kind of in the sling when CNA B and RN A entered the room. CNA B and RN A put the resident on the Hoyer pad and transferred him/her to the bed. The resident did not complain of pain. The resident was quiet. CNA C was trained to use the sit to stand and Hoyer lift on the resident. There were no signs in the resident's room to identify his/her transfer status. Staff used both. He/She was assigned to the resident before. He/She used the lifts interchangeably. There are supposed to be two people for a lift transfer.
He/She did not wait for assistance because CNA B forgot about it. If he/she could do things over, he/she would wait for assistance. During an interview on 10/16/25 at 1:19 P.M., CNA B said him/her and RN A were eating lunch at the nurse's station. They heard screaming. CNA B saw the resident's door closed.
He/She entered the resident's room, and he/she was hanging from the sit to stand lift. His/her knees were
on the base of the lift, and his/her arms were flinging in the air. He/She looked like a string puppet. CNA C was standing next to the lift when CNA B entered the room. CNA B stepped out of the room and asked RN
A for assistance. CNA B and RN A removed the resident from the sling, put the Hoyer pad underneath him/her and transferred him/her to bed. The resident always complained of knee pain. He/She did not complain of pain during the Hoyer transfer. The resident's knee was swollen, and RN A called the doctor.
The doctor requested an x-ray. The resident used to be a sit to stand. The resident moved his/her feet around and the sit to stand was no longer safe. CNA C knew the resident was a Hoyer lift. CNA B and CNA C have transferred the resident together with the Hoyer lift. CNA C should not have transferred the resident by him/herself. CNA C did not ask CNA B for assistance. After the incident, staff discussed ways for staff to know a resident's transfer status. During an interview on 10/16/25 at 2:07 P.M., the interim DON said she has worked at the facility for ten months. The resident was a two person assist. The resident was a Hoyer lift when she started working at the facility. The resident's care plan should have been updated. There is a list of the residents' transfer status in the shower book. Staff should be getting report from the previous shift.
Staff can also ask the nurse if they are unsure of a transfer status. There must always be two people for a lift transfer. CNA C should not have transferred the resident by him/herself. During an interview on 10/17/25 at 8:25 A.M., the administrator said CNA C was terminated. Staff communicate transfer statuses from shift to shift. The nurse should ensure each shift is giving report. He does not think they document when report was given. He reviewed the resident's care plan and thinks it could be interpreted a couple different ways.
He in-serviced staff immediately about the lift policies and two-person requirement. Staff reevaluated all the residents to ensure they are using the proper sling. 2618785
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SSM HEALTH DEPAUL HOSPITAL - ANNA HOUSE in BRIDGETON, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRIDGETON, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SSM HEALTH DEPAUL HOSPITAL - ANNA HOUSE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.