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Date ArticleType
4/30/2019 Regulatory
G/IJ/SSQC Citation Update

A total of 42 recertification surveys were completed by the Indiana State Department of Health in the month of March and of those, four (9.52%) were found to be deficiency free.  One provider received an Immediate Jeopardy citation as follows:

F689- IJ/SSQC – Free of Accidents Hazard/Supervision/Devices for failure to ensure a cognitively impaired resident, who was at risk for elopement received the supervision to prevent elopement from the facility for residents reviewed with exit seeking behaviors.  This failure resulted in the resident leaving the locked unit and then the facility, walking alone in the cold weather, and being picked up in a vehicle by a passerby.  The resident was driven to a family member home. 

Six providers received seven G level citations as follows:
Tag F686 (3 times) – Treatments/Services to Heal Pressure Ulcers

  • Failure to ensure that a resident did not develop an avoidable deep tissue injury for one resident reviewed for pressure ulcers in the sample.  This resulted in actual harm when the resident developed a pressure ulcer (deep tissue injury) to the left great toe that subsequently opened and developed probable osteomyelitis (infection of the bone) requiring debridement of the pressure ulcer and treatment with antibiotics. 
  • Failure to ensure a resident’s pressure ulcers were identified prior to being unstageable, to document which treatment was being used to reassess the effectiveness of the treatment and to follow up on a referral to a wound clinic for one resident reviewed for pressure ulcers.  The residents pressure ulcers of the left posterior ischium were discovered unstageable and progressed into one large area. 
  • One 2567was unavailable for review for this report.

Tag F760 (2 times) – Residents are Free of Significant Medication Errors

  • Failure to administer pain medication as ordered by the physician for one resident reviewed for medication administration.  This resulted in the resident experiencing unrelenting daily pain and aggressive behaviors which required hospitalization.
  • Failure to administer medication as ordered by the physician for a resident reviewed for medication distribution.  The resident did not receive 9 doses of a medication used to treat pulmonary hypertension and was subsequently sent to the Emergency Room and admitted to the hospital for Acute and Chronic Diastolic Heart Failure and Acute and Chronic Hypoxic Respiratory Failure. 

There are two common denominators in the two F760 G level citations:

  • Physician orders were not followed as written
  • Bothevents caused a transfer to the hospital

Recommended Action:

  • Conduct Medication and Treatment Administration Record Audits to identify missed medications and/or treatments and take early action to rectify.

  • Evaluate all transfers to the hospital to determine root cause of the transfer and use the information to strengthen the nursing skill level with education.

Tag F689 (1 time) – Free of Accident Hazards/Supervision/Devices

  • Failure to thoroughly assess fall risk, provide adequate supervision and implement adequate interventions to prevent falls for a resident with a history of intermittent confusion and hallucinations with recent acute increase in confusion and hallucinations frequency related to hypercapnia (elevated carbon dioxide) resulting in a fall with unrepairable bilateral femur fractures for a resident reviewed for accidents.  The facility also failed to implement appropriate fall prevention interventions and supervision for 2 residents. 

Tag 693 (1 time) – Tube Feeding Management/Restore Eating Skills

  • Failure to provide tube feedings as ordered by the physician for a resident reviewed for tube feedings.  This resulted in significant weight loss. 


Email ldavenport@ihca.org with questions or if you want assistance with compliance assessment to prepare for survey.