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Date ArticleType
11/5/2018
G/IJ/SSQC Citation Update - September 2018

There was a total of 34 recertification surveys completed by the Indiana State Department of Health in the month of September and none were found to be deficiency free.  Six providers received Immediate jeopardy citations as follows:

•F600 (2times) SSQC/IJ – Free from Abuse and Neglect
oThe immediate jeopardy was called when the facility failed to protect a resident from physically and verbally being abused by a staff member. 
oThe immediate jeopardy was called when a CNA provided care in an intimidating, physically and verbally abusive manner to residents and was intimidating and verbally abusive to another resident.

•F608 (1time) IJ/SSQC – Reporting of Reasonable Suspicion of a Crime for failure of the facility to ensure that a staff member who had knowledge of an incident of physical, verbal abuse and intimidation, immediately reported those concerns to the facility administrator for 4 or 6 residents. 

•F609 (1 time) IJ/SSQC – Reporting of Alleged Violations for staff failure to report allegations of abuse to management resulting in the risk of physical and psychosocial harm for 6 of 9 residents with allegations of abuse. 

•F610 (1 time) IJ/SSQC – Investigate/Prevent/Correct Alleged Violation for failing to thoroughly investigation allegations of physical and verbal abuse, resulting in a left shoulder and wrist sprain for a resident.

•F679 (1 times) SSQC – Activities Meet Interest/Needs Each Resident for failure to ensure resident were provided with activities designed to meet their interest and their physical mental, and psychosocial well-being. 

•F689 (3 times) IJ/SSQC – Free from Accident Hazards/Supervision/Devices for the following:
oFailure to ensure an effective intervention was in place to prevent elopements for 7 or 7 residents.
oFailure to prevent the elopement of cognitively impaired resident whose whereabouts were unknown from 7pm to 7:15 pm. 
oFailure to provide supervision, safety interventions, and monitor for reoccurrence of self-harm for a resident with known behaviors of wrapping a call light cord around their neck. 

•F698 (1 time) IJ/SSQC – Dialysis for failure to provide immediate assessment and care to a resident in an emergency resulting in excessive bleeding and death. 

There was a total of eleven G level citations as follows:

•F686 (4 times) – Treatments and Services to Prevent / Heal Pressure Ulcers

oFailure to ensure a resident was provided care to prevent the development of multiple state 2 to stage 4 pressure ulcers due to the resident being left on a bed-pan for an undetermined amount of time. 
oFailed to provide wound care to the pressure ulcers as ordered by the physician. 
oFailed to notify the physician of wound changes and implement interventions to prevent the development of pressure areas to right buttock of a resident.  The left heel worsened from a deep tissue injury to an unstageable pressure ulcer and development of a heel pressure ulcer. 
oFailure to ensure a resident with pressure sores received necessary treatment and services to promote healing.

•Failure to provide the care and treatment to a stage 2 pressure ulcer to prevent worsening to an unstageable, larger wound. 

•F689 (4 times) -- Free of Accidents Hazards/Supervision/Devices
oFailure to provide adequate supervision to a severely cognitively impaired resident ot prevent falls for 1 of 3 residents.  This practice resulted in the resident falling and sustaining a fractured left hip that required surgical intervention.
oFailure to provide supervision and appropriate assistive devices (wheel chair) to a cognitively impaired resident who required extensive assistance with all transfers.  This resulted in the resident falling and being transferred to the hospital emergency room and admitted to the hospital with a left side fractured rib. 
oFailure to ensure residents who were at risk to fall were transferred safely.  Failure to also ensure functioning equipment, effective interventions, and adequate supervision for 4 of 7 residents.  A resident obtained a laceration and required 10 sutures to the right forehead
oFailure to prevent a fall.  This resulted in a subarachnoid hemorrhage (bleeding in a space between the brain and tissue covering the brain), failed to ensure an intervention was in place for previsions fall, and failed to complete a full investigation for a resident.

•F684 (1 time) -- Quality of Care for failure to ensure residents received treatment to a diabetic ulcer per the physician orders.  A culture was missed. 

•F658 (1 time) -- Services Provided Meet Professional Standards for failure to ensure a comprehensive assessment and care plan reflected a safe transfer process.  This deficiency resulted in a resident sustaining a tibia/fibula fracture on the right leg during a transfer. 

•F692 (1 time) – Nutrition/Hydration Status Maintenance for failure to comprehensively assess residents’ weight loss and update weight loss care plan interventions to ensure residents maintained acceptable parameters of nutritional status.  This deficient practice resulted in severe weight loss and abnormal labs over a 30-day period. 

Please direct your questions or request for assistance to ldavenport@ihca.org.