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Date ArticleType
8/29/2017 Regulatory
G/IJ/SSQC Citation Update - July 2017

Indiana State Department of Health conducted a total of 47 recertification surveys in the month of July and of those, three or 6.36 percent were found to be deficiency-free. Twelve providers received a total of 16 G level tags. G level tag for July as follows;

F314 (8 times) – Treatment to Prevent Pressure Sores for failure of a facility to ensure treatments were completed as ordered by the physician and treatments and interventions were implemented related to heels not elevated off the bed and low loss air mattress not in place for 3 of 3 residents. Other providers failed to ensure a resident admitted without a pressure wound did not develop a pressure wound, failure to prevent pressure sores and promote healing of pressure sores to a resident identified at risk for pressure sores, and failed to prevent the acquisition and/or the increase in size of a pressure sore on a resident’s heel resulting in an unstageable wound.

F323 (4 times) – Free of Accident Hazards/Supervision/Devices for failure to provide adequate supervision to prevent falls for four of five residents reviewed for accidents. The practice resulted in harm for four residents who required extensive assistance. Another provider failed to ensure fall prevention assessment was completed for a resident with a change of condition relating to falls which resulted in hospitalization. A third provider failed to ensure a resident was protected from injury when a direct care staff member acted alone to provide care to a resident requiring two or more staff for personal care. This resulted in the resident falling from bed during care and receiving a laceration above his right eye which required an Emergency Room visit where nine sutures were required to close the wound. The forth provider failed to ensure a resident who had a history of falls and had recently fallen had interventions and supervision initiated to prevent further falls. The resident fell and received an injury of intracranial hemorrhage and resulted in hospitalization.

F223 (1 time) – Free from Abuse/Involuntary Seclusion for failure to ensure a resident was free from being pushed down by an angry resident which resulted in a fall and a fractured hip.

F520 (1 time) – QAA Committee-Members/Meet Quarterly/Plans for failure of the Quality Assurance Committee to follow and implement a systematic action plan to monitor interventions were followed for the prevention and treatment of pressure sores.

F250 (1 time) – Provision of Medically Related Social Services for failure to ensure medically related social services were provided to address the grief process resulting in increased psychosocial distress for a resident related to the death of a daughter.

F309 (1 time) – Provide Care/Services for Highest Well Being for failure to properly monitor, assess, and notify physician of complaint of pain to dialysis shunt site located on the right groin of resident resulting in diagnosis of sepsis from MRSA and removal of the shunt that required hospitalization.

July SSQC/IJ Tags
Eight providers received a total of nine SSQC/IJ level tags in July. The most frequently cited SSQC/IJ tag was F323 (4 times) – Free of Accident/Hazards/Supervision/Devices for failure to ensure assessment, supervision, and safety interventions were implemented to prevent the elopement of a resident who was a known elopement risk, failure to provide supervision to a resident with dementia, known exit seeking behaviors and identified as an elopement risk, resulting in elopement, failure to ensure the safety of a cognitively impaired resident who exited the facility, unattended, on two separate occasions.

Another provider failed to ensure adequate supervision was maintained related to ensuring Wanderguard and exit doors elopement prevention devices were in working order and exit door alarms were on resulting in cognitively impaired resident exiting the facility unnoticed and found by staff outside the facility.

F329 (2 times) – Drug Regimen is Free from Unnecessary Drugs for failure to obtain a PT (prothrombin time) and INR (international normalized ratio) laboratory blood clotting test for a resident who was receiving Coumadin. Coumadin was ordered by the physician. The practice resulted in hospitalization of a resident for hemoptysis (coughing and spitting up blood), a critically elevated PT/INR level and toxicity and anemia. Another provider failed to obtain a PT (prothrombin time) and INR (international normalized ratio) laboratory blood clotting test for residents who were receiving Coumadin. The practice resulted in in hospitalization for spontaneous bruising, bleeding from multiple wounds and skin tears, and a critically elevated PT/INR level for the resident.

F314 (1 time) – Treatments/Services to Prevent/Heal Pressure Sores for failure to prevent the development of a pressure ulcer and failed to monitor, measure and track the progress or potential progression of the pressure sore.

F225 (1 time) – Investigate/Report Allegations for failure to report an allegation of neglect by a resident against a staff member to the Administrator for investigation with a second allegation of sexual abuse involving the same resident and staff member occurring three days later.

F226 (1 time) – Develop/Implement Abuse/Neglect, ETC Policies for failure to report an allegation of neglect by a resident against a staff member to the Administrator for investigation with a second allegation of sexual abuse involving the same resident and staff member occurring three days later.

Please email ldavenport@ihca.org for questions or needed assistance.