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Date ArticleType
11/6/2017 Regulatory
G/IJ/SSQC Citation Update – September

There was a total of 37 recertification surveys completed by the Indiana State Department of Health in the month of September.  Of those, four (10.81%) were found to be deficiency-free.  Eight providers received six SSQCs and seven IJ’s as follows:

F323- QC/IJ (3 times) - Free of Accident Hazards/Supervision/Devices
• Failure to ensure staff supervision of 8 residents during smoking for 3/6 observations of resident for smoking.
• Failure to ensure a resident who was at risk for self-harm received the supervision to prevent self-harm.  Resident swallowed a battery while in his room and required surgical removal of the battery.
• Failure to ensure adequate supervision was in place when a wheel chair bound resident, with a Wandergard, exited the facility stairs through a fire door and fell 6 stairs.  This resulted in a neck fracture. 

F225 – QC/IJ (2 times) – Investigate/Report Allegations/Individuals
• Failure to prevent abuse in that staff member was observed to physically restrain a resident to prevent getting out of chair, which resulted in three areas of bruising.  The staff member was not escorted immediately from the building or monitored, and the abuse was not immediately reported to the administrator.  The abuse allegation was not thoroughly investigated.  The staff member, hired in 2015 had not had reference checks done. 
• Failure to thoroughly investigate 3-3 staff to resident allegations of abuse to protect residents during the investigation. 

F226 – (2 times) – Develop/Implement Abuse/Neglect, etc. Policies
• (QC) – Failure to ensure the facility policy indicated to report immediately to the administrator.
• (QC/IJ) – Failure to implement written policy procedures that protect and prevent abuse.  After a witnessed physical staff to resident abuse, policies to protect, report, and investigate were not followed.

F155 – IJ (1 time) – Right to Refuse Formulate Advance Directives
• Failure to administer CPR to a resident who had a full code status. 
F223 - SQ/IJ (1 time) – Free From Abuse/Involuntary Seclusion 
• Failure to prevent abuse in that staff member was observed to physically restrain a resident to prevent getting out of chair, which resulted in three areas of bruising. 
F353 – IJ (1 time) – Sprinkler System – Maintenance and Testing
•  Program was performed on 1 of 1 automatic sprinkler piping systems that resulted in immediate jeopardy to residents. 

Eight providers received eight G level citations as follows:

F314 – (2 times) – Treatments to Prevent Pressure Sores
• Failure to implement appropriate interventions to prevent the development or worsening of pressure areas for 3 of 3 residents.

F323 – (2 times) – Free of Accidents Hazards/Supervision/Devices
• Failed to ensure the necessary number of people to assist in transfers to prevent a fall for one resident. Fall resulted in surgical repair of hip fracture and a subdural hematoma.
• Failure to ensure the use of a gait belt while assisting a resident with ambulation, which resulted in a fall when the resident lost his balance and the resident sustained a fractured clavicle.  

F309 – (2 times) – Provide Care/Services for Highest Wellbeing
• Failure to administer pain medications after a fall with complaints of severe pain.  This resulted in the resident yelling and moaning out in pain during movement.
• Failure to ensure residents’ medications were administered as ordered by the physician for 2 of 3 residents.  Resulted in one resident having a seizure and one resident having pain. 

F223 – (1 time) – Free from Abuse/Involuntary Seclusion
• Failure to protect a female resident from verbal abuse by a male resident.

F333 – (1 time) – Resident Free of Significant Medication Errors
• Failure to ensure resident received the correct dose of insulin on 2 different occasions.

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