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Date ArticleType
4/1/2019 Regulatory
G/IJ/SSQC Citation Update

A total of 48 recertification surveys were completed by the Indiana State Department of Health in the month of February and of those, two (4.17%) were found to be deficiency free.  Five providers received five tags – IJ’s/SSQC’s as follows: 

F689 (3 times) IJ/SSQC – Free from Accidents Hazards/Supervision/Devices

  • Failure to ensure a proper resident transfer which resulted in a fall and death.  The resident fell and hit his head and was transferred to the hospital.  The resident expired during the evaluation. The resident fell during a transfer from the bed to the wheel chair.  The CNA was positioned behind the wheel chair and was using a gait belt.  The resident stood up and did a 360 and fell between the bed and the wheel chair. 

  • Failure to provide supervision to prevent a resident, with a known subdural hematoma and altered mental status from exiting the building, and knowing the resident was out of the building, and did not take any steps to locate the resident, for greater than a 10-hour time-frame through the evening and night shift.  The facility also failed to prevent a resident with auditory hallucinations, psychiatric diagnosis and without a physician order to leave the building, did not exit the building unattended, and was found outside in her wheel chair, down the street from the facility by a random family member. 

  • Failed to ensure hot water temperatures were kept at a safe temperature. A staff member was aware of the water temperatures above 120 degrees Fahrenheit and did not notify the administrator

F686 (1 time) IJ/SSQC – Treatment/Services to Prevent/Heal Pressure Ulcers

  • Failure to assess and document a change in resident skin that was later identified as infected, unstageable, ulcer measuring 7 cm in length and 3.2 cm in width. 


F757 (1 time) IJ/SSQC – Drug Regimen is Free from Unnecessary Drugs

  • Failure to monitor a residents PT/INR levels of a resident receiving an anticoagulant drug and notify a physician of a refused lab draw, which resulted in continued administration of an anticoagulant drug and hospitalization secondary to uncontrolled bleeding. 


Fourteen providers received sixteen G level tags as follows:

F686 (5 times) – Treatment/Services to Prevent/Heal Pressure Ulcers

  • Failure to ensure residents received necessary treatment and services to promote healing of pressure ulcers, related to not thoroughly assessing pressure ulcers, not accurately completing weekly skin observations, orders for treatments not obtained timely, and treatments and interventions not completed as ordered, which resulted in a resident’s pressure ulcers becoming a stage three and unstageable. 

  • Failure to complete weekly skin assessments, accurately identify pressure areas, notify the physician, and provide appropriate treatments resulting in an unstageable pressure ulcer to the buttocks, oral antibiotics for symptoms of infections, an unstageable pressure ulcer to the heel, and a stage 2 pressure ulcer to the buttocks. 

  • Failure to provide treatment and services to prevent facility acquired pressure ulcers and resulted in the development of a state 4 pressure ulcer.

  • Failure to ensure interventions were in place to prevent a resident admitted with a red area did not develop a wound, which resulted in progressing to an unstageable pressure area. Once identified, failed to assess, monitor and treat the pressure ulcer.

  • Failure to prevent deterioration of 2 stage II pressure areas to 2 stage III pressure ulcers, provide pressure relief and assessment as directed by the care plan.

F689 (5 times) – Free of Accidents/Hazards/Supervision/Devices

  • Failure to ensure a cognitively impaired resident assessed to exhibit intrusive wandering behavior was provided supervision to prevent the resident from wondering into another resident room and having pushed the other resident resulting in a fractured hip.

  • Failure to maintain a safe environment for a resident with known safety awareness deficiency resulting in an open tibia fracture requiring hospitalization and surgery. 

  • Failure to ensure safety measure were in place related to assisted transfers for a resident who utilized a sideboard and 2 residents observed being transferred by a standup mechanical lift.  This resulted in a resident sustaining a fracture.

  • Failure to provide adequate supervision to prevent falls for a resident with a history of falls.  This resulted in a fracture.

  • Failure to ensure a resident was transferred with assistance of 2 staff members, resulting in a fall with fracture. 

F684 (3 times) – Quality Care

  • Failure to notify a resident’s physician of a change of condition resulting in a resident with low blood pressure and risk of death. 

  • Failure to notify the physician for timely treatment.  Resident was admitted to the hospital with severe ascites and had to have fluid removed. 

  • Failure to assess, monitor and document a resident change of condition related to slurred speech which resulted in admission to the hospital ICU and a diagnosis of sepsis. 

F692 (1 time) – Nutrition/Hydration Status Maintenance

  • Failure to identify, assess and intervene when a resident experienced a significant weight change.  The resident had a 10% weight loss over 60 days.


F760 (1 time) – Residents are Free of Significant Medication Errors

  • Failure to ensure a resident was free of a significant medication error.  This resulted in hospitalization for a drug overdose. 


F697 (1 time) – Pain Management

  • Failure to ensure pain was thoroughly assessed and adequately treated during a pressure ulcer treatment of a dressing change.  The resident was verbally and non-verbally expressing pain. 


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