IHCA/INCAL

News

Click here to access archived news articles.

ARTICLE

Date ArticleType
6/4/2018 Regulatory
G/IJ/SSQC Citation Update – Failure to ensure the resident environment is free of accidents and hazards

The Indiana State Department of Health conducted 50 recertification surveys in the month of April.  Of those, two (4%) were found to be deficiency-free.  Two providers received F689 IJ/SSQC – Free of Accident Hazards/Supervision/Devices as follows:

§483.25(d)(2) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Provider #1 –   Based on interview and record review, the facility failed to ensure the safety of a resident with elopement behaviors who exited the facility, unsupervised.  The Immediate Jeopardy was removed and corrected when the facility completed staff education/in-services on all aspects of the policy/procedure for elopements, elopement drills, and security devices were placed in all windows.  The elopement assessment indicated the resident was at risk for elopement due to being independently mobile and cognitive impairment.  The interventions included to redirect to activity, secure all facility exits, provide one to one attentions/conversation and apply a Wander guard per physician order.  The resident exited the building through the payroll office window, found by staff in the back-parking lot, and then brought back into the facility. 

Provider #2 –  Based on interview and record review, the facility failed to provide the supervision necessary to prevent the reoccurrence of the ingestion of potentially hazardous materials, batteries.  The resident had a history of ingestion of foreign bodies.  The Immediate Jeopardy began when the resident informed the facility staff that he had ingested a battery and ended when the facility instituted monitoring every 15 minutes. 

There were ten providers that received G Level citations in the month of April as follows:

Four providers received F689 – Free of Accident Hazards/Supervision/Devices at the G level of scope and severity as follows:

Provider #1 – Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall and failed to ensure interventions were addressed to prevent further falls.  A resident sustained a fracture of the hip.   

Provider #2 – Based on observation, record review, and interview, the facility failed to ensure a resident received adequate assistance and assistive devices to prevent accidents, related to a dependent resident who was unable to stand being lowered to the floor during a transfer from a shower chair to a Broda chair without the use of a gait belt or mechanical lift.  The resident was then assisted off the floor and into the Broda chair before notifying the nurse of the fall to complete an assessment.  The fall resulted in a closed fracture of the shaft of the left femur and increased pain. 

  • Three CNA’s were transferring the resident after a shower was given, the residents’ knees buckled, and they could not support the resident and the resident was lowered to the floor to her knees.  The resident was then assisted off the floor and back into a Broda chair.  A gait belt was not used.
  • The resident was taken to the nurse and then assessed.  The resident was sitting in the Broda chair without pain however did have red area to the knees. There was no rotation to bilateral legs and hips in the Broda chair assessment by the nurse.
  • Resident was transferred to the Emergency Room and returned with a diagnosis of closed fracture to the left femur.
  • Six days later, an LPN heard a scream from the resident’s room.  CNA was in the room providing care.  The resident was grabbing her left leg.  The CNA explained she was informed in report the resident had a fall earlier in the day. An LPN assigned to the resident had not been informed of the fall.  The left thigh was edematous and approximately three inches above the knee was indented.  There was no redness or bruising and the left leg appeared to be shorter than the right with external rotation.   
  • During an interview with the Director of Nursing, she stated that the CNA’s should not have moved the resident until the nurse assessed the resident after the fall. 

Provider #3 -- Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for a resident reviewed for falls.  This deficient practice resulted in a resident sustaining a hematoma to the right temporal area of the head.   The CNA indicated she had been providing personal care to a resident and had been changing the bed linens.  She indicated the resident had been positioned on her left side, facing the window.  The CAN had gone to the opposite side of the bed to obtain a wash cloth to wash the resident’s back and the resident fell out of the bed.  She called for assistance from the nurse. 

  • A plan of care initiated, and identified as current, addressed the focus of the resident had activities of daily living self-care performance deficit related to deterioration.  The interventions with most recent revision date, included but were not limited to bed mobility.  The resident requires one sometimes two staff participations to reposition and turn in bed.  Bathing: resident is totally dependent on staff to provide a bath and resident is totally dependent on staff for bed mobility.    The resident was using a San Pressure Guard Air mattress. 

Provider #4 – Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent a fall of a resident and failed to ensure fall interventions were in place. The resident sustained a fracture of the left hop and laceration to the head requiring sutures. 

Two providers received F686 – Treatment/Services to Prevent/Heal Pressure Ulcer as follows:

§483.25(b)(1) Pressure ulcers.  Based on the comprehensive assessment of a resident, the facility must ensure that – (i) A resident receives care, consistent with professional standards of practice to prevent pressure ulcers and does not develop ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. 

Provider #1 -- Based on observation, interview and record review the facility failed to prevent a facility acquired, avoidable and unstageable pressure injury from developing for a resident.  The resulted in resident actual harm when developing an unstageable ulcer in the facility

Provider #2 – Based on observation, interview and record review, the facility failed to appropriately assess a pressure ulcer for a resident, resulting in the development of a stage 3 pressure ulcer. 

  • Resident was identified at risk for skin breakdown due to being incontinent.
  • A nursing initial assessment indicated resident had an abrasion to her right trochanter.
  • The medical record showed no treatment/intervention for the documented abrasion.
  • Wound assessment “Wound Pressure Injury Assess w/Braden indicated resident had a stage 3 pressure ulcer to the right buttock. 
  • Observation of the stage 3 pressure ulcer was uncovered, and the nurse indicated that the abrasion was the same area as the documented abrasion. 

One provider reviewed F684 – Quality of Care as follows:

§483.25 Quality of Care is a fundamental principle that applies to all treatment and care provided to facility residents.  Based on the comprehensive assessment of a resident, the facility must ensure that resident receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. 

Based on observation, interview, and record review, the facility failed to provide preventative care and follow up with an alteration in skin integrity that was later identified as an unstageable pressure injury and stage 34 pressure injury for two residents. 

A provider received F692 – Nutrition/Hydration Status Maintenance for failure to ensure residents maintained acceptable parameters of nutritional status resulting in severe weight loss and abnormal labs over a six-month time frame. 

F694 (1 time) – Parenteral/IV Fluids for failure to provide Peripherally Inserted Central Catheter (PICC) care for a resident.  This deficient practice resulted in the resident being hospitalized with septic shock and Coagulase-negative staphylococcus (bacteria that causes infection) cultures growing in both the resident’s blood and the PICC line catheter tip. 

F760 (1 time) – Residents are Free of Significant Medication Errors for failure to prevent a medication error resulting in the hospitalization for a resident.  Medications were intended for roommate that included medications for pain and blood pressure.  An LPN had the medications for roommate, then stepped out to computer to record a vital of roommate while staff completed care.  When the LPN returned to the room she noted that the wrong resident ingested medications. 

If you have questions or need assistance, mail ldavenport@ihca.org.