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Date ArticleType
12/3/2018 Regulatory
Residential Citation Update – October 2018

The Indiana State Department of Health conducted a total of 14 surveys and of those, four (28.57) were found deficiency-free.  There were 17 Offense tags cited, 68 Deficiency tags cited for a total of 85 residential citations for the month of October 2018.  The following Offensive tags were cited:

  • Tag 0051 (2 times) – Residents’ Rights Offense for failure to ensure the right to be free from any physical or chemical restraints for the purposes of discipline or convenience and not required to treat the resident’s medical symptoms was upheld.
  • Tag 0052 (1 time) -- 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 241 (12 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 245 (1 time) -- Health Services Offense for failure to ensure injectable medications are given only by licensed personnel. 
  • Tag 406 (1 time) -- Infection Control Offense for failure to establish and maintain an infection control practice designed to provide a safe, and comfortable environment and to help prevent the development and transmission of disease and infection. 

  The following deficiency tags were cited:

  • Tag 273 (eleven 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 243 (7 times) – Health Services Deficiency for failure to ensure the individual administering the medication documented the administration in the individual’s medication and treatment records that indicate time, name of medication/treatment, dosage (if applicable), and name or initials of the person administering the drug or treatment. 
  • Tag 090 (5 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 117 (5 times) – Personnel Deficiency for failure to ensure staff are 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 and services provided. 
  • Tag 148 (4 times) – Sanitation and Safety Standards Deficiency for failure to maintain buildings, grounds, and equipment in a clean condition, in good repair, and free of hazards that may adversely affect the health and welfare of the residents or the public.
  • Tag 144 (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 provide reasonable comfort for all resident. 
  • Tag 155 (3 times) -- Sanitation and Safety Standards Deficiency for failure to ensure 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 214 (3 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 217 (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 414 (2 times) – Infection Control Deficiency for failure to ensure staff wash their hands after each direct resident contact for which handwashing is indicated by accepted professional standards.
  • Tag 304 (2 times) – Pharmaceutical Services Deficiency for failure medication or treatment cabinets or rooms are always locked except when authorized personnel are present.
  • Tag 246 (2 times) – Health Deficiency for failure to ensure PRN medications administered by a QMA only after authorization by a licensed nurse or physician.  Each contact with a licensed nurse or physician not on the premises for authorization to administer PRN’s to be documented in the nursing notes indicating the time and date of the contact.
  • 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 006 (1 time) Scope of Residential Care Deficiency for failure to discharge a resident if the resident is a danger to the resident or others; requires twenty-four (24) hour per day comprehensive nursing care or comprehensive nursing oversight; requires less than twenty-four (24) hour per day comprehensive nursing oversight, or rehabilitation therapies and has not entered into a contract with an appropriately licensed provider of the resident’s choice to provide those services; is not medically stable; or meets at least two (2) of the following three (3) criteria unless the resident is medically stable and the health facility can meet the resident’s needs:  (A) Requires total assistance with eating.  (B) Requires total assistance with toileting. (c) Requires total assistance with transferring.

 Single citation for the following tags:

  • Residents’ Rights Deficiency (1time) for tags 0027, 0035, 0045, and 0053
  • Administration and Management Deficiency (1 time) for tag 0086
  • Sanitation and Safety Standards Deficiency (1 time) for tags 0145, 0154, and 0156.
  • Health Services Deficiency (1 time) for tags 0247, and 0248
  • Food and Nutritional Services Deficiency (1 time) for tags 0270, 0272 and 0275
  • Pharmaceutical Services Deficiency (1 time) for tags 0298 and 0302

If you would like assistance with survey preparation contact ldavenport@ihca.org.