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G/IJ/SSQC Citation Update

There was a total of 54 recertification surveys completed by the Indiana State Department of Health in the month of June.  Of those, three (11.11%) were found to be deficiency free.  Four providers received SSQC citations and three immediate jeopardy citations as follows:

F695 (1 time) – SSQC/IJ – Respiratory/Tracheostomy Care and Suctioning for failure to provide suctioning and proper oxygenation for a resident with a tracheostomy in an emergency which resulted in hospitalization and subsequent death. 

F600 (1 time) – SSQC/IJ – Free from Abuse and Neglect for failure to protect 3 residents from nonconsensual sexual interactions by a resident resulting in kissing and touching of personal areas.  This had the potential to affect 16 cognitively impaired females residing in the nursing facility.

F609 (1 time) – SSQC/IJ – Reporting of Alleged Abuse for failure to immediately report to the Executive Director and protect residents against nonconsensual sexual interactions by one resident. 

F689 (1 time) – SSQC/IJ – Free from Accidents Hazards Supervision/Devices for failure to supervise a resident with a known aspiration risk, after a meal tray was served in his room while he was in bed. The facility did not follow a physician order to be in the dining room with supervision for meals.  The resident was served dinner in his room, unsupervised, choked, became unresponsive, required CPR and was admitted to the hospital. 

F607 (1 time) – SSQC – Develop and Implement Abuse/Neglect Policies for failure to implement a policy requiring allegations of abuse and injuries of unknown origin to be immediately reported to the Administrator.

Fifteen providers received the following G level citations as follows:

F689 (8 times) – Free from Accidents Hazards/Supervision and Devices

  1. Failure to transfer a resident according to the plan of care.  This deficient practice resulted in a fracture of the left humerus and a fracture to the left tibia. 
  2. Failure to supervise a resident to prevent a fall resulting in a fracture.
  3. Failure to provide services to prevent falls.  A resident required assist of (2) staff and a mechanical lift, had a fall when rolling over in bed.  The resident had to be transferred to the emergency room for a hematoma to the forehead, a laceration on his nose, skin tears to hands and arms, and bruising around the eyes.  The resident had five falls within a year’s times.  Fall interventions were not in place at the time of the falls.
  4. Failure to aid resident with walking in the resident’s room and to ensure implementation of non-skid footwear to maintain safety.  The fall resulted in a hip fracture requiring hospitalization.  
  5. Failure to investigate falls for the root cause analysis and failed to implement fall interventions to prevent further falls resulting in a fractured hip, ribs and head injuries. 
  6. Failed to ensure three room containing hazardous materials were locked as indicated by facility policy for 16 residents residing in the nursing facility.  Residents were cognitively impaired and mobile.
  7. Failure to provide adequate supervision to residents who were at risk for falling and failed to prevent falls.  This resulted in a resident sustaining intracranial   injuries, rib fractures and a left hip fracture and a clavicle fracture. 
  8. Failure to implement care planned interventions resulting in a right hip fracture requiring medical treatment and intervention. 

F760 (2 times) – Residents are Free of Significant Med Errors for failure to ensure medication errors. This resulted in a resident receiving the wrong medication resulting in unresponsiveness and being sent to the emergency room for evaluation and diagnosis of a drug overdose. 

F698 (1 time) – Dialysis for failure to obtain physician orders for a dressing treatment on a new port placement for a resident receiving dialysis, resulting in hospitalization for sepsis, and failed to ensure a resident’s fistula site was assessed every shift for 2 of 3 residents. 

F600 (1 time) – Free from Abuse and Neglect for failure to ensure a resident was free from being hit with a belt by another resident.  This resulted in bruising to the right eye and abrasions to the right leg, right arm and right hand. 

F686 (1 time) – Treatment and Services to Prevent/Heal Pressure Ulcers/Injury for failure to ensure a resident did not develop a stage 3 pressure ulcer and failed to notify the physician timely of a deterioration in the pressure ulcer. 

F744 (1 time) – Treatment and Services for Dementia for failure to provide care and services to support psychosocial well-being for (2) residents.  This resulted in an increase of anxiety and increase in psychoactive medication. 

F684 (1 time) – Quality of Care for failure to implement physician orders after a hospital discharge which resulted in another hospitalization.  The resident had a weight gain of 17 pounds in 20 days with no notification to the physician and the resident developed difficulty breathing due to fluid volume overload. 

F693 (1 time) – Tube Feeding Management/Restore Eating Skills for failure to ensure feeding tube placement was checked prior to flushing the tube and failed to accurately monitor the feeding tube intake for 2 residents.  This resulted in a resident being hospitalized with a diagnosis including hypernatremia and elevated sodium levels.

Please direct your questions to ldavenport@ihca.org.