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Date ArticleType
10/1/2018 Regulatory
G/IJ/SSQC Citation Update – August 2018

There was a total of 56 recertification surveys completed by the Indiana State Department of Health in the month of August 2018.  Of those, four (7.14%) were found to be deficiency free.  Six providers received Immediate jeopardy citations as follows:

F600 (2times) SSQC/IJ – Free from Abuse and Neglect
• Failure to prevent resident to resident abuse for 3 of 7 residents reviewed for abuse.  Failed to ensure interventions were in place for the supervision of a resident with a known history of physical contact towards other residents.  The immediate jeopardy began when Resident B entered a resident’s room and inappropriately physically touched him.  Resident B then approached another resident and touched on his genital area while in public.  Resident B then approached another resident having his groin area rubbed during an activity.  The immediate jeopardy was removed when interviews with staff confirmed the facility had begun educating staff on abuse and the reporting process and monitoring Resident B.
• Failed to prevent sexual abuse to 2 female residents from a male resident with known sexual behaviors.  The immediate jeopardy began when a female resident reported an allegation of abuse. 

F578 (1 time) IJ – Request/Refuse/Discontinue Treatment/Formulate Advanced Directive
• Failure to ensure a resident’s code status was accurately documented in a medical record to ensure a resident’s wishes to not be resuscitated were followed.  This resulted in a resident receiving life saving measures when respirations and pulse ceased, including the administration of IV medications and mechanical ventilation. 

F602 (1 time) SSQC – Free from Misappropriation/Exploitation
• Failed to prevent resident funds from being diverted to other accounts, including staff personal accounts for 31 of 36 residents in the facility.  The Business Office Manager diverted funds to accounts including her personal account. 

F678 (1 time) SSQC/IJ – Cardiopulmonary Resuscitation (CPR)
• Failed to obtain a code status on a resident, and in the absence of orders, failed to preform cardiopulmonary resuscitation on a resident when he showed signs and symptoms of respiratory and cardiac arrest.  The immediate jeopardy began when the facility failed to initiate CPR when a resident’s vital signs had ceased.  The resident’s power of attorney elected not to execute advanced directives with the understanding the facility staff would respond to medical emergencies with CPR measures and a full code would be instituted. 

F689 (1 time) SSQC/IJ – Free from Accidents Hazards/Supervision and Devices
• Failed to ensure a resident was not left outside and the resident was without a method to contact staff.  A resident was taken outside into the courtyard around 7:00 pm by a staff member.  She was placed on a three-person swing.  After being outside for a period, she tried to stand but could not because of a flaccid arm.  She lost balance and fell to the concrete and landed on her buttock.  She indicated darkness was falling and the doors were closed. She yelled for assistance and no one came.   She laid on the concrete for 2-3 hours.  She indicated she was scared and upset.  She laid on the concrete until a staff heard her calling and two staff assisted her to stand.  She indicated she asked staff what time it was, and she was informed it was 1:00 am.  She did not get her medications including her insulin while she was outside. 

The following G level citations as follows:
F686 (2 times) – Treatments and Services to Prevent/Heal Pressure Ulcers
• Failure to ensure appropriate treatments were in place for two residents.  This resulted in the worsening of pressure ulcers.  There were observed omissions in the Medication and Treatment Records for both residents.  Resident refused to shower, turn and reposition, and use the bed pan. 
• Failed to prevent acquired pressure ulcers and failed to prevent the worsening of pressure ulcers for a resident. 

F600 (1 time) – Free from Abuse and neglect
• Failure to prevent verbal abuse resulting in a resident experiencing mental anguish.

F689 (1 time) – Free from Accident Hazards/Supervision and Devices
• Failure to ensure a resident was transferred with a mechanical lift and or gait belt.  This resulted in the resident being lowed to the floor and obtaining a left humeral fracture.  Failure to document the incident in the medical record, notify the physician and/or the resident representative. 

F580 (1 time) – Notify of Changes (Injury/Decline/Room Change)
• Failed to notify the physician of a resident’s complaints of odor and drainage of a diabetic foot ulcer wound, resulting in maggots being found in the wound.  Also failed to notify the physician of the appearance of maggots, resulting in psychological harm. 

F658 – Services Provided Meet Professional Standards
• Failed to manage the wound care of a diabetic foot wound by failing to assess drainage and odor of the wound, notify the physician of a resident’s complaints of odor and drainage of a wound.  This resulted in maggots being found in the wound.  The physician was not notified of the maggots resulting in psychological harm. 

Notify ldavenport@ihca.org of any questions.