IHCA/INCAL

News

Click here to access archived news articles.

ARTICLE

Date ArticleType
4/27/2017 Regulatory
G/IJ/SSQC Citations and Regulatory Update

The Indiana State Department of Health conducted a total of 39 Recertification surveys for the month of March,  five or 12.82 percent of which were deficiency free. There was a total of nine G level federal tags cited in seven locations throughout Indiana. The G level federals tags were for F323 (4 times), F314 (2 times), F309 (1 time), F325 (1 times) and F328 (1 time).

#1 -- F323 – Free of Accident Hazards/Supervision/Devices – Failure to ensure the facility policy and procedure of two staff members for mechanical lift transfers was followed resulting in a resident having fallen from the lift during the transfer and sustained a scalp laceration which required sutures for closure.

#2 – F323 – Failure to provide adequate supervision for a resident related to fall intervention not in place resulting in a resident falling and obtaining a fibula fracture. The resident fell on the 20th and complained of left ankle pain. An X-ray was obtained and there was evidence of a fibula fracture. Care planned intervention were to not leave the at bedside after placing the resident in bed and to place an alarm to alter staff when the resident attempted to get out of bed without assistance.

#3 – F323 – Failure to implement fall prevention interventions. During a transfer the resident missed the wheel chair and fell to the floor. One staff member was transferring the resident however the care planned intervention was for two staff to always use a gait belt.

#4 – F323 – Failure to ensure the safety of a resident while being transferred using a mechanical lift. The resident sustained a fracture to the right arm during the transfer. The staff member completing the transfer knew of the injury and did not report it.

#1 -- F314 – Treatments to Prevent/Heal Pressure Sores – Failure to ensure a resident who was admitted to the facility without a pressure ulcer, received waffle boots, offloading heels, and skin prep as care planned and/or ordered by the physician. The resident developed an unstageable pressure ulcer.

#2 – F314 – Failure to ensure interventions and treatment were in place for a resident who was identified at an increased risk for developing pressure ulcers which resulted in a stage 3 pressure ulcer to both heels.

F328 – Treatment for Special Needs – Failure to ensure a resident who was dependent on a tube feeding had adequate calorie requirements met, which resulted in an unplanned weight loss.

F325 – Maintain Nutrition Status Unless Unavoidable – Failure to ensure a resident who was dependent on a tube feeding had adequate calorie requirements met, which resulted in an unplanned weight loss.

F309 – Provide Care/Services for Highest Well Being – Failure to provide the necessary assessment and interventions for resident after injury of unknown origin to the right arm. Resident was not assessed for pain or pain interventions implemented during the day as the resident yelled out in pain throughout the day.

There were two IJs and two SSQC citations for the month of March issued to three separate facilities.
F225 (SS/F) – Investigate/Report Allegations/Individuals – Failure to thoroughly investigate an allegation of abuse timely to the Administrator of the facility.

F226 (SS/F) – Development Abuse/Neglect etc. Policies – Failure to follow the facility’s abuse policy related to investigating an allegation of verbal abuse, protecting the residents from staff member during an investigation of an allegation of abuse, and reporting an allegation of abuse timely to the Administrator of the facility.

F353 (SS/K) – Sprinkler System /Maintenance and Testing – Failure to follow recommendations from inspector to have a sprinkler system flush preformed.

F155 (SS/K) – Right to Refuse Formulate Advanced Directives – Failure to immediately initiate CPR for a resident who requested a full code status and was found unresponsive and staff knowing where to find resident code status in the electronic medical record.

F309 (SS/K) – Provide Care/Services for Highest Well Being – Failure to ensure appropriate equipment was available for staff to respond effectively to an emergent situation nor require nursing staff to have current APR certification.

Contact Lori Davenport at ldavenport@ihca.org for questions or assistance.