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Date ArticleType
2/4/2019 Regulatory
G/IJ/SSQC Citation Updates

There were a total of 38 recertification surveys completed by the Indiana State Department of Health in the month of December and of those, three (7.89 %) were found to be deficiency free.  Seven providers received the following G level citations:

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

  • Failed to ensure fall preventative interventions were implemented resulting in a fall with multiple fractures for a resident reviewed for falls.  While the resident was being assisted with care the resident complained of pain, was grabbing her left hip and her leg was drawn up.  The resident also complained of pain in the right wrist when her blood pressure was being taken.  Assessments were completed at the time of the fall and again when the resident began to complain of pain.  Physician, family, and administration of the facility was notified when the resident was transferred to the hospital emergency department for evaluation.  The emergency room reported the resident had right radial and femoral head fractures.  The resident required surgery to repair the right hip and radial fractures.  On a later date, it was brought to the DHS’s attention by a different nurse that at the time of the incident it took 3 people to get the resident up – RN, QMA and CNA) and that the resident had been crying out in discomfort.  It was determined, after further investigation, that the facility policy was not followed. 
  • Failed to provide adequate supervision to prevent a fall for a resident reviewed for accidents.  This resulted in a fracture of the right hip of a cognitively impaired resident with Lewy Bodies and a recent history of other falls.  Resident was attending a church services and the resident was left unattended and without supervision of a facility staff.
  • Failed to develop and implement interventions to manage a resident’s falls and failed to provide supervision for a resident resulting in a fall with a back fracture; and failed to utilize a mechanical lift per the plan of care, resulting in a fall with a right arm fracture for 2 residents reviewed for falls. 

F692 (1 time) – Nutrition/Hydration Status Maintenance
The facility failed to ensure a newly admitted resident with non-pressure wounds with multiple drains, history of weight loss, underweight status according to the Body Mass Index (BMI), and multiple antibiotics and vitamin supplements was assessed by a Registered Dietician (RD) in a timely manner which resulted in a significant weight loss and hospitalization.  The facility also failed to follow the RD recommendations for a resident with a history of weight loss for 2 of 3 residents reviewed for weight loss. 

F684 (1 time) – Quality Care 
Failed to provide care and services to meet the physical needs for a resident reviewed.  The result of the practice was a bowel obstruction requiring hospitalization. Resident went 8 days without a bowel movement and has a history of constipation.  The documented pattern of bowel evacuation is every 2-3 days.   

F600 (1 time) – Free from Abuse and Neglect
Failed to transfer a resident to the hospital due to a change of condition per the family’s wishes for residents sampled for neglect.  This resulted in delay in transferring the resident to the hospital, in which the resident was admitted to the hospital with a diagnosis of acute respiratory failure and intubated in the emergency room. 

F740 (1 time) – Behavioral Health Services 
Failed to develop a behavior management program to address the resident’s refusal of care for residents reviewed for resistive behaviors.  This resulted in hospitalization and required surgery. 

Four providers received the following IJ/QC citations as follows:

F600 (2 times) – Free from Abuse and Neglect
Failure to ensure staff to resident sexual abuse did not occur. 
Failedto prevent sexual abuse to a female resident from a male resident with known hypersexual activity. 

F609 (1 time) – Reporting of Alleged Violations
Failed to immediately report an allegation of resident to resident abuse to the Administrator and State Agency.

F610 (1 time) – Investigate/Prevent/Correct Alleged Violations
Failed to ensure an allegation of sexual abuse, was thoroughly investigated for an allegation of sexual abuse.

F686 (1 time) – Treatments/Services to Prevent/Heal Pressure Ulcers
Failed to prevent the worsening of, follow physician’s orders and effectively treat a State 4 pressure ulcer to a resident’s coccyx for 2 residents.  The immediate jeopardy was called when the facility failed to ensure a resident received timely assessment and treatment of a Stage 4 pressure ulcer which resulted in hospitalization with a diagnosis of osteomyelitis and requiring surgical debridement. 

F678 (1 time) – Cardio-Pulmonary Resuscitation (CPR)
Failed to ensure Cardio-Pulmonary Resuscitation (CPR) interventions were initiated for a resident observed with absence of vital signs when no physician orders or advanced directives were noted for the resident not to receive CPR or other resuscitation measures, resulting in death.  This had the potential to affect all residents in the facility with a Full Code Status. 

F690 (1 time) – Bowel /Bladder Incontinence, Catheter, UTI
Failed to assess and provide catheter care to a resident who was experiencing decreased urine output from an indwelling catheter bag and leaking urine around catheter tubing which resulted in a distended bladder palpable to the naval and urine retention of 2000 ml. The immediate jeopardy was called when the facility failed to ensure catheter care was provided to a resident with an indwelling catheter that resulted in hospitalization to the ICU with a distended bladder, acute UTI and sepsis.

Please contact Lori Davenport if you have any questions or need assistance: ldavenport@ihca.org