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Date ArticleType
IJ/SSQC/G Citations Update – December 2017

The New survey processes has been fully implemented and December marks the first full month of that process.  There were a total of 39 recertification surveys completed by the Indiana Department of Health in the month of December 2017.  Of those, three (7.69%) were found to be deficiency free.  Two facilities received two IJs/SSQC citations. 

The following are the IJ/SSQC citations:

• F678 – SS/IJ (1 time) – Cardio-Pulmonary Resuscitation (CPR)
§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives. 
Based on interview and record review the facility failed to follow a resident/representative’s wishes (Advance Directives) to resuscitate (full Code) for a resident. 

• F603 – SS/IJ (1 time) – Free from Involuntary Seclusion
§483.12(a) The facility must –
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
Based on observation, interview, and record review, the facility failed to perform a comprehensive assessment, obtain physician order, and consent of the resident’s legal representative prior to placement of a resident on a locked dementia unit. 

1. During the initial tour, resident was observed sitting in a high back w/c in the dining room of the locked memory care unit.  The resident had her back away from the rest of the dining room and was facing the wall where music played from a radio. The resident was observed holding a stuffed dog and was wiping her glasses with her sweater.  There was no activity programming in progress on the unit.   Resident indicated she was waiting to move to a new apartment in Fort Wayne and was ready to leave. 

2. The census report did not list the resident as residing on the locked memory care unit.  The resident was listed as residing in an unlocked area of the facility.  A female bed was not available on the locked memory care unit. 

3. An employee interview indicated that the resident was sleeping in a recliner chair located on locked units living room area and not in her assigned bed in an unlocked unit. 

4. Behavior tracking did not indicate exit seeking behavior was tracked and or occurring prior or after resident was placed on the locked unit. 

5. Interviews with staff indicated the resident had exit seeking behaviors and hallucinations. 

6. The resident was placed on the locked unit for her safety and monitoring. 

7. The resident representative indicated not having knowledge of exit seeking behavior or the placement on the locked unit.  

Four providers received G level citation in December.  The following are the G level citations:
F690 (1 time) – Bowel/Bladder Incontinence – Catheter, UTI for failure to provide treatment and services for an indwelling urinary catheter to prevent the development of a urinary tract infection (UTI) and sepsis that resulted in a hospitalization for a resident. 

F692 (1 time) – Nutrition/Hydration Status Maintenance for failure to ensure a resident was weighed on admission, failed to notify the physician of weight losses, and failed to monitor fluid intake in a resident with a decreased intake and thickened liquids, resulting in hospitalization with diagnosis including dehydration. 

F684 (1 time) – Quality of Care for failure to ensure a resident’s admission medication, physician orders were written from appropriate hospital discharge document accurately.  The deficient practice resulted in a resident’s morning blood sugar dropping to 14.  The resident was unresponsive and admitted to the hospital in the Intensive Care Unit on he ventilator. 

F689 (1 time) – Free from Accidents/hazards/Supervision/Devices for failure to ensure each resident received adequate supervision and assistance to prevent falls.  Two of the residents’ falls resulted in a major injury.

If you have questions or would like assistance with survey readiness, email ldavenport@ihca.org.