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Date ArticleType
4/30/2018 Regulatory
G/IJ/SSQC Citation Update

There was a total of 39 recertification surveys completed by the Indiana State Department of Health in the month of March.  Of those, three (7.69%) were found to be deficiency free. 

Three providers received SSQC/IJ’s as follows:
F689 (2 times) - IJ/SSQC – Free of Accident Hazards/Supervision/Devices
Provider #1 – Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place when a cognitively impaired resident, excited the facility through the front door and was located off the property. 
Provider #2 – Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident, who was at risk for elopement, received the supervision to prevent elopement from the facility.  This resulted in the resident being out of the facility without supervision for approximately 30 minutes and picked up by a citizen approximately ¼ mile from the facility. 

F 678 (1 time) -  IJ/ SSQC Cardio-Pulmonary Resuscitation
Based on interview and record review, the facility failed to provide basic life support, including CPR to a resident with a physician order for a full code status (CPR) for closed records reviewed for death.  The failure to provide basic life support, resulted in the resident’s death. 

Fifteen provides received seventeen G level federal tags as follows:
Tag F686 (7 times) -- Treatments and Services to Prevent/Heal Pressure Ulcer

  • The facility failed to ensure a resident admitted without pressure ulcers was provided effective interventions to prevent the development of a pressure area on the left buttock, mid-back and to the right posterior thigh.
  • The facility failed to ensure skin assessments were completed weekly for a resident.  This resulted in the development of a facility acquired Stage 3 and Stage 4 pressure ulcer.
  • The facility failed to ensure residents who admitted with no pressure ulcers, did not develop a pressure related skin injury for a resident.   The deficient practice resulted in a resident developing a suspected Deep Tissue Injury to the right heel.
  • The facility failed to ensure implementation of care plan interventions to prevent the development of a stage II pressure ulcer and worsening of the pressure ulcer to a stage III for a resident.
  • The facility failed to assess the worsening of signs and symptoms of a pressure ulcer infection resulting in the hospitalization for treatment with intravenous antibiotics for a resident
  • The facility failed to ensure interventions to prevent development of a pressure ulcer were in place for a resident.   This resulted in development of a stage II pressure ulcer. (partial -thickness skin loss with exposed dermis- may present as an intact blister).
  • The facility failed to ensure residents who were admitted with no pressure ulcers did not develop a pressure related injury for a resident and failed to accurately assess a pressure ulcer for a resident. 

Tag F689 (3 times) – Free of Accident Hazards/Supervision/Devices

  • The facility failed to ensure proper fall interventions were implemented for 3 residents.  The practice resulted in a fall causing acute rib fractures for a resident. 
  • The facility failed to conduct an IDT (interdisciplinary team) post fall analysis and implement interventions after a fall event, in which a fall occurred that resulted in a facial fracture.
  • The facility failed to identify an environmental hazard related to improper placement of a fire extinguisher.  The fire extinguisher expelled hazardous chemicals upon impact with the floor and created an unsafe atmospheric environment for 14 residents. Of the 14 residents sent to the hospital, one resident was admitted for inhalation injury. 

Tag F690 – Bowel and Bladder Incontinence

  • The facility failed to supply catheter supplies for a resident with urinary retention. This resulted in a urinary tract infection secondary to the resident being unable to completely empty bladder. 

Tag F695 – Respiratory/Tracheostomy Care and Suctioning

  • The facility failed to ensure a hospital physician’s order for a CPAP (Continuous Positive Airway Pressure) was clarified in regard to use and settings, failed to document if and when the CAPAP was used, filed to notify the physician that the resident was not using the CAPAP, and failed to do a thorough respiratory assessment when the resident complained of shortness of air resulting in hospitalization for acute on chronic respiratory failure.

F600 – Free from Abuse and Neglect

  • The facility failed to ensure a resident was free from physical abuse by staff feeding him in a rough manner.  The facility also failed to ensure a resident was free from verbal and psychosocial stress by staff talking in a derogatory manner to 2 residents.

F684 Quality of Care

  • The facility failed to ensure a resident with edema was monitored and physician response timely to prevent the resident from being hospitalized with generalized body edema and failed to ensure daily weights were completed and monitoring for complication of deep vein thrombosis and bilateral pulmonary embolism for 2 residents of three reviewed for disease management.

F580 – Notify of Changes (Injury/Decline/Room, etc.)

  • The facility failed to ensure a resident’s Physician was notified of a critical Digoxin level results in a timely manner and failed to ensure a family member was notified the resident was sent to the ER (Emergency Room) after a change of condition for 2 residents reviewed for notification of change.  A resident was admitted to the hospital, because of the critical Digoxin level not being called to the resident’s Physician in a timely manner to receive treatment to decrease the Digoxin level and prevent Digoxin toxicity.

F692 – Nutrition/Hydration Status Maintenance

  • The facility failed to implement weight loss interventions for significant weight loss for 2 residents being reviewed for significant weight loss.  Resident lost 32 pounds or 13.1% weight loss in 90 days and another resident lost 63 pounds or 20.9% of weight in 90 days, which was significant weight loss. 

F760 – Residents Free of Significant

  • The facility failed to ensure a resident’s Physician was notified of a critical Digoxin (medication used to treat heart conditions) level in a timely manner to prevent further doses from being administered for residents reviewed for significant medication errors.  The resulted in a resident being administered the same continued dose of Digoxin when already with a critically high Digoxin level.  The resident was admitted to the hospital with Digoxin Toxicity

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