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Date ArticleType
1/7/2019 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 and of those, four (11.11%) were found to be deficiency free.  Nine providers received the following G level citations:

F689 (3 times) – Free of Accident Hazards/Supervision/Devices 

  • Failed to ensure staff did not leave a resident unattended in her room while in a wheelchair which resulted in a fall with diagnosed neck fracture and 3 sutures to the forehead for a resident reviewed for falls. 
  • Failed to implement fall interventions for 2 residents reviewed for accidents.  This deficient practice resulted in a resident falling and becoming unresponsive and receiving 6 staples to her head. 
  • Failed to transfer a resident with a mechanical lift and assistance of two staff members for a resident reviewed for accidents.  This deficient practice resulted in a resident sustaining a fractured left arm.  

F760 (3 times) – Residents are Free of Significant Medication Errors 

  • Failed to ensure residents were free of significant medication errors related to a medication to lower ammonia levels not administered as per hospital discharge medications list.  This resulted in a resident requiring re-admission to the hospital for treatment for a resident reviewed for medication administration upon admission from the hospital. 
  • Failed to ensure residents were free from significant medication errors for a resident reviewed for significant medication error.  This deficient practice resulted in a resident having an altered mental status, being intubated and presenting in the emergency room with two opioid medication patches. 
  • Failed to provide medications to a resident who was suffering from a migraine as prescribed by the physician resulting in harm when the resident was hospitalized with the migraine.  Failed to ensure medications were administered as ordered by the physician.

F686 (2 times) – Treatment/Services to Prevent/Heal Pressure Ulcer

  • Failed to ensure a resident’s knee immobilizer was removed for thorough skin assessments, resulting in an unstageable pressure ulcer, and then failed to ensure the physician was notified of changes in the pressure ulcer, ultimately resulting in hospitalization of a resident reviewed related to pressure ulcers. 
  • Failed to provide treatment and services to prevent and care for pressure ulcers for 4 residents with pressure ulcers.  This practice resulted in progression of one pressure ulcer to a Stage 4 wound with tunneling, undermining and infection. 

Tag 684 (1 time) – Quality of Care

  • Failed to provide non-pressure wound treatments per physician orders which resulted in harm when a resident had to be hospitalized for wound deterioration and infection for a resident reviewed for medication and treatment administration.  The facility failed to administer prescribed medications and document why the medications were not given as ordered and failed to assess and follow physician’s orders related to an implanted port device.

Tag 690 (1 time) – Bowel/Bladder Incontinence, Catheter, UTI 

  • Failed to provide urinary catheter care for a resident reviewed for urinary catheters.  This deficient practice resulted in the resident arriving to the hospital in poor condition with severe sepsis, acute kidney injury, and dehydration.  The facility also failed to provide an appropriate rationale for the urinary catheter for a resident reviewed for urinary catheter use.

One provider received the following immediate jeopardy citations:

F678 (1 time) IJ/QC – Cardio-Pulmonary Resuscitation 

  • Failed to perform Cardio-Pulmonary Resuscitation (CPR) according to the resident’s code status preferences of a resident reviewed for death.  The facility also failed to follow the CPR procedure for unresponsive residents for a resident reviewed for death.  The Immediate Jeopardy began, when the facility failed to initiate CPR on a resident found unresponsive.  The IJ was removed when the facility in-serviced staff on resident code status, CPR procedure, and conducted practice Code Blue scenarios.  – noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for the more than minimal harm that is not immediate jeopardy because the facility is continuing in-servicing of staff, and monitoring of staff knowledge of CPR and resident code status.

F684 (1 time) IJ/QC – Quality of Care 

  • Failed to ensure a resident with complaints of pain, nausea and who became unresponsive was assessed by a licensed staff for a change in condition for a resident reviewed for death. The Immediate Jeopardy began when the facility failed to assess a resident who had been complaining of nausea, pain and had a fever, and failed to perform an assessment on a resident prior to instructing a CNA who was not certified to perform CPR on a resident.   The immediate jeopardy was removed, when the facility audited all the residents’ records for recent change in condition and in-services staff on change of condition, resident code status, CPR procedure and conducted practice CODE BLUE scenarios, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy