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Date ArticleType
8/1/2016 Regulatory
G/IJ/SSQC Citation Update

The Indiana State Department of Health conducted a total of 53 Recertification surveys for the month of June 2016. Of the 53 Recertification surveys 6 or 11.32 percent were deficiency free. There was a total of 20 G level federal tags cited in 16 locations throughout Indiana. The most frequently cited G level federals tags were for F323 (7 times), F325 (4 times) and F314 (4 times). Other tags cited this month were F520, F241, F333, F309, and F328 (1 time/each).

F323 was cited for the following reasons:
Failure to ensure a resident who required staff assistance for activates of daily living, did not ambulate, and required use of mechanical lift for transfers, did not suffer an injury of unknown origin requiring physician intervention and ongoing treatment,
Failure to ensure adequate supervision for a cognitively impaired, dependent resident which resulted in a fall.
Failure to ensure adequate supervision was provided to prevent a resident fall. Failed to ensure fait belt was used while ambulating a resident. Utilization of alarms in place of supervision, resulting in falls with head lacerations, cerebral bleeding and a fracture.
Failure to determine an appropriate root cause analysis, implement appropriate interventions or and failure to ensure restorative rehabilitation services for ambulation and toileting and close supervision were provided for a resident candidate for restorative programs and required close supervision.

F325 was cited for the following reasons:
Failure to maintain acceptable nutritional parameters related to tube feeding not administered at the ordered rate and weekly weights not completed resulting in significant weight loss. Failed to ensure a resident maintained acceptable parameters of nutrition related to monitoring and assessment of supplemental intake, weekly weights completion as well as being seen by a registered dietician.
Failure to notify physician of dietary recommendations for interventions for a resident with ongoing significant weight loss.

F314 was cited for the following reasons:
Failure to ensure a resident who was admitted without identified pressure sores or other wounds did not develop pressure sores.
Failure to ensure treatment and interventions were obtained for pressure ulcers, resulting in worsening of pressure ulcer and failure to ensure dietary recommendations were followed for a resident with pressure ulcers, resulting in wound, resulting in deterioration of a wound.
Failure to ensure appropriate wound assessments were performed.

There were five IJs and five SSQC citations for the month of June issued to three separate facilities. The most frequently cited IJ/SSQC tags were for F309 (3 times), F323 (2 times), F281 (2 times), F157, F282 and F224 were cited 1 time each. F309 w for failure to provide necessary services related to lack of through assessment by a licensed nurse prior to moving a resident after a fall, administration of oral medication to a resident with an altered mental status and failure to ensure the emergency medical system was sought after a resident fell, hit their head and was bleeding from the ear canal. F309 was also cited for failure to provide nursing assessment, failure to notify the physician of significant change of condition, failure to follow physician orders and care plans. F323 was cited for failure to ensure supervision and interventions to prevent a resident identified at risk for falls. The resident fell 9 times in 10 months resulting in a fracture to the arm, hip and wrist as well as lacerations to the forehead. Another facility failed to provide supervision necessary to prevent elopement from a secured dementia unit. The resident was in immediate harm because whereabouts were unknown. F281 was cited when a facility failed to meet professional standards of resident care related to lack of assessment by a licensed nurse prior to moving a resident after a fall. The resident hit their head, was bleeding, causing subdural hemorrhages resulting in death. F157 was cited for failure to notify the physician of significant changes in resident condition in a timely manner. One facility did not assess vital signs, respond to a significant weight gain, or respond to an excessively high blood pressure. Another facility failed to notify the physician and/or family when there was a change in output, fluid restriction, Shortness of breath and oxygen saturation levels. Residents in all situations had a diagnosis of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Kidney Failure, Hypertension and localized edema.

If you have any questions, please contact Lori Davenport, Director of Regulatory Clinical Affairs at ldavenport@ihca.org.