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Date ArticleType
10/1/2018 Regulatory
Residential Citation Update – August 2018

The Indiana State Department of Health conducted a total of 13 surveys and of those, three (25%) were found deficiency-free.  There were fourteen Offense tags cited, 76 Deficiency tags cited for a total of 90 residential citations for the month of August 2018.  The following Offensive tags were cited:

Tag 0051 (1 time) – Residents’ Right Offense for the failure to ensure the resident right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required treat the resident’s medical symptoms. 

Tag 0052 (2 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 (7 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. 

Tag 0242 (1 time) – Health Services Offense for failure to ensure to ensure the resident was observed for effects of medications.  Documentation of undesirable effects to be contained in the clinical record.  The physician notified immediately if undesirable effects occur, and such notification shall be documented in the clinical record. 

Tag 0406 (3 times) – Infection Control Offense for failure to establish and maintain an infection control practice designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of diseases and infection.  The following Deficiency tags were cited:

The following Deficiency tags were cited:

Tag 0273 (10 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 0148 (6 times) – Sanitation and Safety Standards Deficiency for failure to maintain buildings, grounds and equipment in a clean condition, in god repair, and free of hazards that may adversely affect the health and welfare of the resident or the public as follows:  1) Each facility shall establish and implement a written program for maintenance to ensure the continued upkeep of the facility.  2) The electrical system, including appliances, cords, switches, alternative power sources, fore alarm and detection systems, to be maintained to guarantee safe functioning and compliance with state electrical codes.  3) All plumbing to function properly and comply with state plumbing codes. 4) At least yearly, heating and ventilating systems shall be inspected. 

Tag 0117 (5 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 0217 (5 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 090 (4 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. 

Tag 0414 (4 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 029 (3 times) – Residents’ Rights Deficiency for failure to ensure residents were treated with consideration, respect, and recognition of their dignity and individuality. 

Tag 0144 (3 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 (3 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 0272 (3 times) – Food and Nutritional Services Deficiency for failure to ensure all food is served at a safe and appropriate temperature.  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 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 0036 (2 times) – Residents’ Rights Deficiency for failure to immediately consult the resident’s physician and the resident’s legal representative when the facility has noticed: 1) a significant decline in the resident’s physical, mental, or psychosocial status: or 2) a need to alter treatment significantly, that is, a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment. 

Tag 0154 (2 times) – Sanitation and Safety Standards Deficiency for failure to keep kitchens, kitchen areas, common dining areas, equipment, and utensils clean, free from litter and rubbish, and maintained in good repair in accordance with 410 IAC 7-24. 

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 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 0247 (2 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 300 (2 times) – Pharmaceutical Services Deficiency for failure to ensure the labeling of over-the-counter medications, prescription drugs, and biologicals used in the facility. 

Tag 301 (2 times) – Pharmaceutical Services Deficiency for failure to ensure labeling of prescription drugs include the following: (A) Resident’s full name. (B) Physician’s name. (C) Prescription number. (D) Name and strength of drug. (E) Directions for use (F) Date of issue and expiration date (when applicable). (G) Name and address of the pharmacy that filled the prescription.  If the medication is packaged in a unit dose, reasonable variations that comply with acceptable pharmaceutical procedures are permitted. 

There were single citations for the following tags:  006, 0035, 0041, 0044, 0048, 0054, 0055, 0118, 0145, 0147, 0215, and 0268.

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