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Date ArticleType
9/5/2018 Regulatory
Residential Citation Update – July 2018

Residential Citation Update – July 2018

The Indiana State Department of Health conducted a total of 15 surveys and of those, four (26.67%) were found deficiency-free.  There were thirteen Offense tags cited, 69 Deficiency tags cited for a total of 82 residential citations for the month of July 2018.  The following Offensive tags were cited:

Tag 0052 (6 times) -- Residents’ Rights Offense for failure to ensure the right to be free from 1) sexual abuse; 2) physical abuse; 3) mental abuse; 4) corporal punishment; 5) neglect, and 6) involuntary seclusion.

Tag 0241 (5 times) – Health Services Offense for failure to ensure the administration of medications and provision of residential nursing care shall be as ordered by the resident’s physician and shall be supervised by a licensed nurse on the premises or on call as follows: (1) Medication shall be administered by licensed nursing personnel or qualified medication aides. 

The following Deficiency tags were cited:

Tag 0273 (9 times) – Food and Nutritional Services Noncompliance for failure to ensure an organized food service department directed by a supervisor competent in food service management and knowledge in sanitation standards, food handling, food preparation and meal service.

Tag 0117 (6 times) – Personnel Deficiency for failure to ensure staff was enough in number, qualifications, and training in accordance with applicable state laws and rules to meet the twenty-four (24) hour scheduled and unscheduled needs of the residents.  The number, qualifications and training of staff shall depend on skills required to provide for specific needs of the residents. 

Tag 0144 (5 times) – Sanitation and Safety Standards Deficiency for failure to ensure the facility was clean, orderly, and in a state of good repair, both inside and out, and shall provide reasonable comfort for all residents. 

Tag 0246 (4 times) – Health Services Deficiency for failure to ensure PRN medications administered by a QMA only upon authorization by a licensed nurse or physician.   The QMA must receive appropriate authorization for each administration of a PRN medication.  All contacts with a nurse or physician not on the premises for authorization to administer PRNs shall be documented in the nursing notes indicating the time and date of the contact. 

Tag 0247 (4 times) – Health Services Deficiency for failure to ensure any error in medications administration shall be noted in the resident’s record.  The physician shall be notified of any error in medication administration when there are any actual or potential detrimental effects to the resident. 

Tag 0029 (3 times) – Residents’ Rights Deficiency for failure to treat residents with consideration, respect, and recognition of their dignity and individuality. 

Tag 0217 (3 times) – Evaluation Deficiency for failure to ensure following completion of an evaluation, the facility, using appropriately trained staff members, identified and documented the services to be provided by the facility as follows:  1) The services offered to the individual resident are appropriate to scope, frequency, need and preference of the resident. 

Tag 304 (3 times) – Pharmaceutical Services Deficiency for failure to ensure medication or treatment cabinets or rooms are always appropriately locked except when authorized personnel are present.  Schedule II drugs administered by the facility shall be kept in individual containers under double lock and stored in a substantially constructed box, cabinet, or mobile drug storage unit. 

Tag 0414 (2 times) – Infection Control Deficiency for failure to ensure requirement of staff to wash their hands after each direct resident contact or which handwashing is indicated by accepted professional practice.  

Tag 0302 (2 times) – Pharmaceutical Services Deficiency for failure to ensure over-the-counter medications must be identified with the following:  A) Resident name B) Physician name C) Expiration date D) Name of drug E) Strength.  

Tag 0240 (2 times) – Health Services Deficiency for failure to ensue personal care, assistance with activities of daily living is provided based upon individual needs and preferences. 

Tag 214 (2 times) -- Evaluation Deficiency for failure to ensure an evaluation of the individual needs of each resident is initiated prior to admission and updated at least semiannually and upon a known substantial change in a resident condition, or more often at the request of the resident or facility. A licensed nurse will evaluate the nursing needs of the resident. 

Tag 0178 (2 times) – Physical Plan Standards Deficiency for failure of the facility to ensure adequate plumbing, heating, and ventilating systems as governed by rules of the fire prevention and building safety commission (675IAC).  Plumbing, heating, and ventilating systems shall be maintained in normal operating condition and utilized as necessary to provide comfortable temperatures in all areas. 

Tag 0155 (2 times) – Sanitation and Safety Standards Deficiency for failure of the facility to have an effective garbage and waste disposal program in accordance with 410 IAC 7-24.  Provision shall be made for the safe and sanitary disposal of solid waste, including dressings, needles, syringes, and similar items. 

Tag 0147 (2 times) – Sanitation and Safety Standards Deficiency for failure to comply with fire and safety standards, including the rules of the state fire prevention and building safety commission (675 IAC) where applicable for health facilities. 

Tag 090 (2 times) – Administration and Management Deficiency for failure to inform the division within twenty-four (24) hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident. 

There were single citations for the following tags:  054, 055, 086, 0148, 052, 0154, 0187, 0243, 0268, 0275, 0298, 0300, and 0326. 

If you have questions or need assistance in preparing for your annual survey, email ldavenport@ihca.org