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Date ArticleType
3/3/2019 Regulatory
G/IJ/SSQC Citation Update - January 2019

A total of 47 recertification surveys completed by the Indiana State Department of Health in the month of January and of those, four (8.51%) were found to be deficiency free.  Four providers received seven tags – IJ’s/SSQC’s as follows:

F600 (2 times) – Free from Abuse and Neglect

- Failure to prevent staff to resident sexual abuse. 

- Facility failed to protect residents from sexual abuse from a known sexually inappropriate resident. 

F609 (2 times) – Reporting Alleged Violations

- Failure to immediately report an allegation of sexual abuse to the Administrator and the ISDH.

F610 (2 times) – Investigate/Prevent/Correct Alleged Violations

- Failure to investigate and implement interventions to prevent a sexual abuse allegation. 

- Failure to conduct a through investigation for an abuse allegation, resulting in immediate jeopardy. 

F686 (1 time) – Treatments/ Services to Prevent Heal Pressure Ulcer

Failure to ensure residents were provided the care and services to prevent the worsening of a stage IV (4) pressure ulcer and/or multiple pressure ulcers.  During a confidential interview with a facility nurse it was indicated that she thought “the wound should not look the way it does, and it was due to the lack of help.  The staffing was horrible, and the resident’s wound was the worst that I have ever seen it.  Staff indicated “they had come in several times to find treatments that had been left in place for days.  They had heard from another nurse that the resident had been left all night with the would vac in place but turned off.  Another nurse stated, “this was the worst I had ever seen the wounds in the facility, and staff were not turning the resident.”

The most frequently cited G Level tag for 2018 and for January 2019 is for F689 for Free of Accidents Hazards/Supervision/ Devices. 

F689 (5 times) was cited as follows: 

- Failure to ensure appropriate safety interventions were implemented for an ambulatory resident with poor safety awareness and indwelling catheter use resulting in a fall requiring surgical intervention to remove catheter tip from behind the bladder and ensuring a resident was safely transferred with two staff members using a Hoyer lift resulting in a fall with head laceration and brain bleed.

- Failure to ensure safety precautions were utilized to prevent from being hit by the meal tray hall cart which resulted in 2 fractures to a resident’s left leg. 

- Failure to provide supervision for a resident with a history of falls.  This resulted in the resident falling and sustaining a fracture to her right femur and requiring surgical intervention. 

- Failure to ensure a resident’s bed rail fit appropriately which resulted in the entrapment of the right leg and a fracture of the left greater trochanteric at the pubic ramus.

- Failure to follow and update a resident’s plan of care for two-person assistance with transfers and utilize a gait belt during a transfer that resulted in resident being lowered to the floor and later identified with a right humerus fracture, failed to utilize a gait belt during a transfer and failed to transfer a resident with two staff as care planned. 

F686 (2 times) – Treatments and Services to Prevent/Heal Pressure Ulcers

- Failure to ensure the pressure ulcer treatment was consistently performed as ordered by the wound care physician, resulting in a worsening of a pressure wound with resulting hospitalizations for infection and exposed tendon. 

- Failure to properly assess and provide treatment to a pressure ulcer to a resident’s right hip resulting in a DTI (deep tissue injury) developing, an unstageable pressure to buttock and unstageable pressure ulcers to heels and stage 2 pressure ulcers to buttocks for 3 residents.

F580 (1 time) -- Notify of Changes (injury/decline/room, etc.) 
Failure to notify family members and physicians regarding resident’s change of condition status.  This resulted in a resident not receiving timely care for a neurological change and change in health condition resulting in death and another resident being hospitalized for hyponatremia. 

F609 (1 time) – Reporting Alleged Violations

F760 (1 time) – Residents are Free of Significant Medication Errors
Failure to provide treatment and care to prevent significant medication error resulting in a resident’s hospitalization.  Appeared to be large gaps in documented medication administration. 

If you have questions or need assistance, email ldavenport@ihca.org