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Date ArticleType
12/3/2018 Regulatory
G/IJ/SSQC Citation Update – October 2018

There was a total of 57 recertification surveys completed by the Indiana State Department of Health in the month of October and of those, three (5.26) were found to be deficiency free.  Four providers received Immediate jeopardy citations as follows:

Tag K211 (1 time) IJ – Means of Egress – General for failure to ensure the means for egress for 1 of several resident rooms was continuously maintained free of all obstructions to full use in case of emergency in accordance with LSC 7.1 10.1 as required by LSC 19.2.1.  The IJ was identified when it was discovered the door latch for a resident room was not functioning properly, causing the door when closed, to prevent access/discharge into or from the room.  The door would not reopen without the use of a tool.  The problem existed for a period, however was not corrected.  Interview The only way to enter the resident room was to enter another resident room with an adjoining bathroom.  The bathroom did not meet the requirements for means of egress. 

Tag F689 (1 time) IJ/QC – Free of Accidents Hazards/Supervision/Devices for failure to ensure a severely cognitively impaired resident, who was at risk for elopement, received the supervision to prevent elopement from the memory care locked unit.  This failure resulted in the resident being without supervision and exposure to hazardous conditions.  The IJ began when a severely cognitively impaired resident was left unsupervised at a medical appointment where he left the doctor office and was found across the street at a hotel.  The resident had a history of elopement and interventions listed within the care plan were not in place to prevent reoccurrence.

Tag F686 (1 time) IJQC – Treatments/Services to Prevent/Heal Pressure Ulcer for failure to provide treatment and services for a resident at high risk for pressure ulcers related to failure to assess a new alteration in skin integrity, obtain treatment for the new pressure ulcer, implement non-medical interventions to promote healing, and failure to report a new pressure ulcer areas to Wound Nurse or any Interdisciplinary team members to assess and implement a treatment plan.  This resulted in the development of a new stage IV pressure ulcer.  The IJ began when the Wound Nurse and the Wound Care Physician found a new, unreported Stage 4 pressure ulcer covered by a dressing on a resident sacrum. 

Tag F698 (1 time) IJ/QC – Dialysis for failure to ensure that peritoneal dialysis care was provided to two residents by not following physician orders, by not following infection control and prevention standards, and not having trained staff to provide peritoneal dialysis care resulting in the development of septic shock. 

  • Resident interview indicated she was concerned with cleanliness of her peritoneal dialysis treatments because some staff were not using masks and gloves while they connected and disconnected her from the dialysis.  The resident also indicated some staff had not been trained on how to connect and disconnect her.  The resident also indicated the time of disconnect was unreliable and often untimely. 
  • Physician orders indicated the resident was to be weighed twice a day (once a night prior to going on the cycler and once in the morning after the resident was taken off the cycler). Blood pressure, specific conditions for physician notification and laboratory perimeters were also ordered. 
  • Physician orders were not followed, and documentation had omissions.  Resident and resident representatives’ grievances were not addressed to resolution. 

A total of fourteen providers received G level citations in October as follows:

F689 (6 times) – Free of Accidents Hazards/Supervision/Devices

  • Failed to ensure a safe transfer, resulting in a resident experiencing a fractured fibula on her right leg for a resident reviewed for accidents.  Staff took a resident to the bathroom and left the resident on the toilet while still hooked up to the stand-up mechanical lift.  When the staff returned to the resident to assist her off the toilet, they lifted the stand lift and heard a loud “pop”.  The staff indicated one of the straps had come off the stand lift and the resident fell from the lift and hurt her leg.  The facility practice was not to leave a resident alone on the toilet connected to a mechanical lift.
  • Failed to ensure a resident was being transferred following her care plan to prevent an accident. This practice resulted in a resident being diagnosed with a fractured fibula and tibia bones. 
  • Failed to implement continuous assessments to 1 of 4 residents reviewed for falls with injury.  This resulted in a resident being hospitalized with a large right frontal subdural hematoma requiring surgical intervention. Neurological assessments were not documented per the facility policy.
  • Failed to safely provide a bed bath to a totally dependent resident resulting in the resident falling out of bed and sustaining bruises and a facial laceration that required 7 sutures.
  • Failed to provide adequate supervision and intervention to prevent falls for a resident.  This resulted in the resident sustaining a subdural hematoma and subarachnoid hemorrhage. 
  • Failed to implement fall interventions, re-evaluate a resident for transfer assistance, and follow post fall procedures resulting in harm when a resident sustained a subdural hematoma and subarachnoid hemorrhage with an unwitnessed fall.  The facility failed to protect a resident from the potential for harm related to falls by not assessing a resident’s fall risk with a change in condition and updating a resident’s transfer assistance requirements on the care plan.

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

  • Failed to implement a plan of care for pressure ulcers for a resident.  The failure resulted in development of an unstageable pressure ulcer (full thickness skin tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) for a resident reviewed for pressure ulcers.
  • Failed to prevent a resident admitted with a red area to receive appropriate intervention to prevent the development of two stage 2 and two unstageable pressure areas for a resident reviewed for pressure ulcers. 
  • Failed to prevent the development of a pressure area and failed to add interventions to aid in the healing of acquired pressure injuries for 2 of 6 residents reviewed for pressure ulcers.
  • Failed to prevent the development of unstageable and stage 3 pressure injuries in 3 of 4 residents.

F684 (2 times) – Quality Care

  • Failure to ensure a resident with a right heel wound, that developed an infection, was treated to prevent worsening of the infection resulting in surgical intervention to the heel wound and amputation of three toes on the right foot and not preventing a hospitalization related to a pulmonary embolism.
  • Failed to protect 2 residents from sustaining a major injury, resulting in harm after falls when staff failed to call 911 immediately and assess a resident with a head injury prior to moving the resident after a fall resulting in a subdural hematoma and subarachnoid hemorrhage.  Also failed to protect resident when staff failed to transfer a resident by a lift resulting in a left rib fracture.  The facility failed to follow policy to protect 2 of 5 residents from the potential of harm after a fall by not appropriately assessing the resident post fall, not following the facility’s lift policy, and not following care plans at the time of the falls. 

    F745 (1 time) – Provision of Medically Related Social Services
  • Failed to ensure a resident received transportation for a scheduled surgery.  The deficient practice resulted in a resident having prolonged discomfort and pain and surgery being postponed for approximately 2 months.

F603 (1 time) – Free from Involuntary Seclusion

  • Failed to ensure a resident who was placed on a locked dementia unit related to an attempted elopement was removed from the locked unit and returned to normal place of residence within the facility after behaviors subsided and the facility entrance was secured.  This resulted in 10 days of repeated tearfulness and verbalizations of believing she was in a mental hospital and wanting to return to her home.  

F580 (1 time) – Notify of Changes (Injury/Decline/Room)

  • Failed to timely notify a resident’s physician of a fall and of x-ray result, resulting in right hip pain and delayed hospitalization for the treatment of a right hip fracture.

F600 (1 time) – Free from Abuse and Neglect

  • Failed to protect a resident from abuse after an allegation had been made of a staff member retaliating against a resident.  This resulted in the resident crying and expressing fear of retaliation. 

Please forward questions or requests for assistance to ldavenport@ihca.org