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Date ArticleType
12/6/2016 Regulatory
G/SSQC Citation Update - September and October 2016

The Indiana State Department of Health conducted a total of 36 recertification surveys and 4 of the 36 were deficiency free or 11.11 percent in September.  One facility received an IJ/SSQC citation for F323 – Free of Accident Hazards/Supervision.  The facility failed to follow their elopement policy to thoroughly check resident whereabouts when a door alarm sounded on a locked unit.  The resident exited the building and was not identified as having eloped for greater than 2 hours. There were 17 G level tags cited in 15 facilities in the month of September.  The G level tags cited are the following:

F309 (5 times) – Failure to properly assess a resident with diagnosis of CHF exacerbation and pneumonia and report abnormal laboratory results and x-ray to the provider in a timely manner as ordered.  Resident was transported to the hospital for treatment. Failure to completely assess a resident with mental status change, and failed to recognize and document areas of skin impairment, resulting in hospitalization for a CVA and a wound infection which spread to the heart.  Failed to recognize, evaluate, develop and implement interventions to manage pain during incontinence care, wound care and repositioning. Failure to communicate with dialysis center.
F323 (4 times) – Failure to ensure adequate supervision was in place to prevent a resident with a security bracelet from exiting the facility without supervision and failed to follow policy and procedure to identify the resident had left the facility. Failure to ensure adequate supervision was provided and fall interventions consistently implemented on the secured dementia unit to prevent falls and accidents resulting in a laceration to the head, concussion and a fractured hip. Failed to provide supervision to resident with behaviors resulting in injury of three residents. Failure to ensure timely care without delay for resident with fractured hip.
F223 (3 times) – Failure to ensure residents were free from sexual abusive sexual behaviors. Failure to ensure a resident was not abused by violation of their privacy and dignity when photos of exposed torso and groin were taken and transmitted by faculty staff to a family member by cell phone. Failure to ensure residents were free of mental and verbal abuse causing a feeling of humiliation.
F157 (2 times) – Failure to notify a resident physician in a timely manner, related to change in status of a skin abrasion, for which a resident was admitted to the hospital due to infection and required IV antibiotics. Failure to notify the family and physician of a residents change of condition, resulting in hospitalization.
F314 (2 times) – Failure to ensure resident received treatment and services to promote healing of pressure sores and prevention of infections, related to treatment without a physician order of a pressure area, a physician was not notified timely for a change of condition, resulting in hospitalization.
F329 (1 time) -- Failure to ensure a resident was free of necessary drugs, failed to ensure physicians orders for the discontinuation of blood pressure medications was followed resulting in hospitalization for low blood pressure.

In October, the Indiana State Department of Health conducted a total of 40 recertification surveys and 1 or 2.50 percent were found to be deficiency free.  One facility received an IJ/SSQC citation for F323 – Free of Accident Hazard/Supervision.  The facility failed to ensure a portable oxygen concentrator was stored a safe distance from the heat of a functioning hair dryer and the facility further failed to ensure salon equipment was inspected routinely for good operating condition as well as lack of supervision of a resident in the beauty shop.  The facility also failed to ensure beauticians had been trained in the use of a fire extinguishers and not using aerosol hair spray in the presence of a resident with oxygen.  There were 14 G level tags cited in 11 facilities in October.  The G level tags cited are the following:

F323 (4 times) – Failure to ensure residents were free from accident.  Fail interventions were not in place, resulting in a skull fracture and subarachnoid hemorrhage.  Failure to prevent a confused resident from wandering into another resident’s room causing resident to hit another resident in the face.  Failure to prevent falls which resulted in a resident falling out of bed, receiving a subdural bleed resulting in death. Failure to prevent injuries of unknown origin for a congenitally impaired, dependent resident
F309 (2 times) – Failure to access and notify the physician of 11 loose stools in 4 days resulting in hospitalization for treatment of c-diff.  Failure to ensure a resident received the necessary treatment and services, related to not obtaining glucometer checks for a resident with diabetes mellitus and family concerns about the blood sugar monitoring.
F314 (2 times) – Failure to ensure care was provided to a resident admitted with pressure ulcers, did not experience deterioration of the pressure ulcer and did not develop additional pressure ulcer. 
F315 (1 time) – Failure to ensure a Foley catheter was medically necessary
F520 (1 time) – Failure to identify non-compliance for ensuring interventions were in place and root cause analysis had been determined for fall, pharmacy reviews were being completed timely, and a system in place to follow infection control issue through the quality assurance protocol. 
F157 (1 time) – Failure to notify a physician in a timely manner, related to a family concern about blood sugar monitoring, for which the resident had hyperglycemia and was admitted to the hospital.
F327 (1 time) – Failure to ensure residents identified as being at risk for dehydration was monitored to ensure sufficient fluid intake was maintained which resulted in hospitalization for treatment.
F250 (1 time) – Failure to manage resident behaviors, resulting in resident wandering uninvited, and a resident hitting another resident in the face.
F223 (1 time) – Failure to ensure residents were free from verbal abuse. 

Please email any questions to Lori Davenport at ldavenport@ihca.org.