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Date ArticleType
10/3/2016 Regulatory
G/IJ/SSQC August Citation Update

The Indiana State Department of Health conducted a total of 48 Recertification surveys for the month of August 2016. Of the forty-eight (48) Recertification surveys three (3) or 6.25 percent were deficiency free. There was a total of 18 G level federal tags cited in 12 locations. The most frequently cited G level federal tags were for F323 (4) times, F223 (2) times, F309 (2) times and F226 (2 times). Other G level tags cited one time each were F224, F225, F221, F282, F425, and F279.

F323 was cited for the following reasons:

  • Failure to provide appropriate transfer technique for a dependent resident which resulted in a fall causing left femur fracture.
  • Failure to ensure a resident received adequate supervision and assistance during transfers in that a resident who required maximum assist of
  • Two for transfers sustained a fracture of the ankle while being transferred by an insufficient number of staff. The staff also failed to immediately notify the nurse when the resident got her foot caught during the transfer.
  • Failed to ensure a root cause and analysis were completed and new fall preventive interventions were implemented.
  • Failed to ensure a dependent resident received the necessary supervision and care to be free of hazards to prevent a large hematoma on the head, skin tears, and a left femur fracture.

F 223 was cited twice for failure to ensure residents were free from abuse. In one situation a staff member raised her voice during a conversation with a resident. F309 was cited for failure to provide nursing assessments in a timely manner related to vital signs as indicated by the resident condition, and physician notification. Resident with bradycardia (abnormally low heart rate) and hypothermia (abnormally low temperature). This deficient practice resulted in harm he resident to the resident as the resident developed septic shock requiring intubation (breathing tube machine).

There were three locations receiving three (3) Immediate Jeopardy and SSQC citations. Federal tags cited were F226, F225, F314, and F323. The tags were cited for the following reasons:

  • Failure to complete skin assessments for resident with low risk for skin impairment. This resulted in a resident at low risk for skin impairment developing a Stage 4 pressure area with bone exposure, hospitalization and surgical debridement.
  • Failure to ensure mechanical slings were inspected and maintained according to manufacturer’s directions to prevent a strap on a sling from breaking resulting in resident failing from a lifted position to the floor and hurting his back.
  • Failure to protect resident during an abuse investigation, report allegations timely, identify allegations as potential abuse, and investigate allegations thoroughly, after allegations of abuse were reported.
  • Failure to implement 4 out of 7 components of abuse policy after allegations of abuse were reported.

If you have any questions or need assistance, please contact Lori Davenport at ldavenport@ihca.org.