F0689

E

Improper Transfer Techniques and Unsafe Storage of Antiseptic Solution

Kirkwood, Missouri Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe transfer techniques with a mechanical lift and during assisted transfers, as well as failure to safely store a topical antiseptic solution. The facility’s Total Lift Transfer policy required staff to position the lift near the receiving surface, lock bed or chair wheels, open the legs of the lift, and maintain contact with the resident to guide and steady them during transfers. Despite this, surveyors observed that during a Hoyer lift transfer for a resident with dementia, anxiety disorder, depression, and total dependence for transfers, staff did not open the legs of the lift and did not maintain physical contact or guidance while the resident was being moved from the bed. The resident’s care plan specified use of a Hoyer lift with extensive to total assistance, but there was no specific transfer order in the electronic physician order sheet.

In another case, a resident with severe cognitive impairment, traumatic brain dysfunction, dementia, and dependence on staff for transfers was observed being weighed using a Hoyer lift. The resident’s care plan required a Hoyer lift with two staff members for transfers. During the observation, staff positioned the wheelchair between the legs of the lift and locked the wheelchair, but after lifting the resident, one CNA moved the Hoyer lift with the legs closed while another CNA stood beside the resident with hands barely touching the resident. In interviews, one CNA stated that he/she typically closed the legs of the Hoyer when the resident was in the air because it felt like better balance, while an LPN and the DON both stated that the legs of the Hoyer should be opened during transfers to provide a stable base and that two staff should be involved, with one guiding the resident.

The facility also failed to follow its Gait Belt Transfer policy, which required use of a gait belt for residents needing one-person assist with transfers. A resident with severe cognitive impairment, dementia, heart disease, heart failure, and a need for maximum assistance with transfers was observed being transferred by an LPN from bed to wheelchair without a gait belt, despite two gait belts hanging above the bed. The LPN lifted the resident under the arms and by pulling on the resident’s pants to pivot them into the wheelchair. Staff interviews confirmed that gait belts should be used for residents requiring assistance with transfers and ambulation, and the DON stated that pulling on a resident’s pants to transfer them was not acceptable. Additionally, a cognitively impaired resident with dementia, anxiety disorder, and depression was observed multiple times with an uncapped bottle of Dakin’s 0.125% solution sitting on a television stand in the room, despite the product’s warning that it was for external use only and should not be taken internally. The solution remained open and accessible in the room even when the resident was not present, and there was no physician order for the Dakin’s solution in the electronic physician order sheet.