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Date ArticleType
9/5/2018 Regulatory
G/IJ/SSQC Citation Update

There were a total of 45 recertification surveys completed by the Indiana State Department of Health in the month of July.  Of those, two (4.44%) were found to be deficiency free.  Four providers received SSQC/IJ’s as follows:

F689 (2 times) SSQC/IJ – Free of Accident Hazards/Supervision/Devices

  • Failure to provide supervision to prevent a resident with known behaviors of hitting, kicking, punching and physical aggression prior to admission from engaging in three residents to resident altercations involving physical and sexual aggressiveness for 3 or 3 incidents.  The Immediate Jeopardy was announced after the resident has his second resident to resident physical altercation of allegedly striking another resident in the face with a coffee cup, after which facility staff did not provide adequate supervision which led to the third altercation of sexual aggressiveness. 
  • Failure to provide adequate supervision of a dependent resident resulting in the resident being stuck in an elevator for three hours.  The Immediate Jeopardy was announced when the facility failed to supervise a resident, when he was placed in the elevator for dinner at approximately 6:00 pm without staff supervision.  The resident was discovered missing during 7:30 rounds.  The resident was released from the elevator at 9:10 pm. 

 F600 (1 time) SSQC/IJ – Free from Abuse and Neglect

  • Failure to protect a cognitively impaired non-verbal resident from abuse by another resident who had a history of sexually inappropriate behaviors.  The Immediate Jeopardy was announced when a resident made a sexually inappropriate comment to another resident and touched the resident’s genital area.  A staff member witnessed the comment being made, did not intervene at the time. 

 F610 (1 time) SSQC – Investigate/Prevent/Correct Alleged Violation

  • Failure to thoroughly investigate allegations of verbal and physical abuse for 6 of 6 residents reviewed. 

 F609 (1 time) SSQC – Reporting of Alleged Violations

  • Failure to report allegations of verbal and physical abuse to local state agency in 6 of 6 residents reviewed. 

 Ten providers received a total of twelve G level citations and they are as follows:

 F689 (4 times) – Free of Accidents Hazards/Supervision/Devices

  • Failure to ensure supervision to prevent an elopement on a heat advisory day.  This resulted in a transfer to the emergency room to receive intravenous fluids for a diagnosis of heat exhaustion. 
  • Failure to provide adequate supervision related to staff leaving a resident unattended on the toilet in the bathroom resulting in a laceration and fracture. 
  • Failure to provide adequate supervision of a resident at high risk of falls when the resident was ambulating which resulted in the resident falling and obtaining a laceration to her head requiring hospitalization and 3 staples.
  • Failed to provide an elopement assessment and supervision for a confused resident.

 F686 (3 times) – Treatment/Services to Prevent/Heal Pressure Ulcer

  • Failure to ensure dependent resident admitted with pressure ulcers were provided effective interventions to prevent redevelopment of and/or worsening of pressure ulcers.  A healed pressure ulcer re-opened after not receiving treatments as ordered and a resident with two Stage 3 pressure ulcers developed into state 4 pressure ulcers on the coccyx and left heel. 
  • Failure to identify and prevent the development and progress of multiple pressure ulcers.  This resulted in the resident developing multiple unstageable pressure ulcers. 
  • Failure to prevent an unstageable pressure ulcer to the posterior right heel. 

 F690 (1 time) – Bowel/Bladder Incontinence, Catheter

  • Failure to ensure a resident with a Foley catheter received appropriate services.  A urine specimen was inappropriately collected.  This resulted in a catheter balloon to deflate and increased penile bleeding. 

 F692 (1 time) – Nutrition/Hydration Status Maintenance

  • Failure to ensure no significant weight loss.  Resulting in a weight loss of 14% in 6 months. 

 F659 (1 time) – Qualified Persons

  • Failure to administer a medication via appropriate route for an unresponsive resident which resulted in the resident requiring emergency services and hospitalization for hypoglycemia. 

 F610 (1 time) – Investigate/Prevent/Correct Alleged Violations

  • Failure to investigate the alleged injury of unknown origin.  A resident was observed to have a large bruise located on her chest and the investigation into the resident’s injury was not started immediately after the allegation was made by staff to the supervising nurse. 

 F600 (1 time) – Free from Abuse and Neglect

Failure to ensure a resident was not forced to go to her room, was not physically restrained while ADL care was provided, then forced to go to bed against her will.  The resident had abrasions to her arms and had a bruise to her back and buttock after being forced into her room, then into her bed and she was forced to change into her nightgown from her clothes after she refused. 

Please direct questions to ldavenport@ihca.org