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Date ArticleType
1/3/2018 Regulatory
G/IJ/SSQC Citation Update

There were a total of 36 recertification surveys completed by the Indiana State Department of Health in the month of November. Of those, four (11.11%) were found to be deficiency-free.  Only one provider was cited with F314 (IJ/SSQC) – Treatment and services to prevent pressure ulcers. The provider failed to identify pressure ulcers on admission, failed to obtain a treatment order for the pressure ulcers until the 12th day of admission, and failed to make treatment changes when weekly monitoring indicated deterioration of the pressure ulcer.  The resident was transferred to the hospital because of the deficient practice. 

Seven providers received nine G-Level tags as follows:

F314 (4 times) – Treatment/Services to Prevent Pressure Ulcers.

  • Failure to prevent pressure ulcer development for a resident on bedrest, resulting in a stage 3 pressure area t the right and left buttock.
  • Failure to provide services and prevent occurrence and to promote the healing of facility acquired pressure ulcers.  This practice resulted in the resident acquiring unstageable pressure ulcer to her feet. 
  • Failure to ensure residents who were admitted with no pressure ulcers, did not develop pressure ulcers.  This practice resulted in a resident developing an unstageable pressure injury to the right heal. 
  • Failure to discover a pressure ulcer until it was a stage 3.  The facility also staged the pressure ulcer as a stage 2 even though slough was present. 

F309(2 times) – Provide Care/Services for Highest Well Being

  • Failure to ensure complete assessment of wounds were completed and dressing changes were completed as ordered to wounds on a resident’s toes. The resident was hospitalized requiring treatment for infected wounds. 
  • Failure to ensure the resident received necessary care and services related to assessment of resident with condition changes of elevated temperature, swallowing, chewing problems, altered physical status, and signs of dehydration.  Resident was hospitalized for sepsis and dehydration. 

F323(1 time)- Free of Accident Hazards Supervision and Devices

  • Failure to provide foot pedals to a resident’s wheel chair that were required due to bilateral lower extremity weakness that resulted in an ankle fracture from the foot falling to the floor and being caught under the wheel chair during transportation. 

F760 (1 time) – Free of Significant Medication Errors

  • Failure to administer a controlled substance at the prescribed dose, twice in a six-hour time period.  The resident received an accidental overdose of Morphine Sulfate Concentrate which resulted in a resident requiring hospitalization, where condition declined, and she expired. 

F157 (1 time) – Notify of Changes/Injury/Decline/Room Changes

  • Failure to notify a physician by phone timely related to a change of condition for which the resident was admitted to the hospital and diagnosed with sepsis and dehydration. 

If you have any questions, email ldavenport@ihca.org