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Date ArticleType
6/4/2019 Regulatory
G/IJ/SSQC Citation Update

A total of 52 recertification surveys were completed by the Indiana State Department of Health in the month of April and of those, four (7.69%) were found to be deficiency free.  Five providers received six total IJ/SSQC citations. 

The most frequently cited federal tag continues to be F689 – Free of Accidents/Supervision and Devices for the following:

G Level – F689 – Free of Accident, Hazards/Supervision/Devices

  • Failure to ensure interventions were in place to prevent a resident with a decline in cognition from being burned related to hot coffee for a resident reviewed for accidents.
  • Failure to ensure residents were free from accidents for 2 residents reviewed for falls. Assistance and fall intervention were not in place, which resulted in a resident receiving a femur fracture and subsequent surgical intervention, and another resident receiving a skin teat and hematoma. 
  • Failure to provide competent resident care by failure to use a gait belt during a transfer and failure to have a post-surgical stump protector in place for a resident. This practice resulted in the resident requiring surgery to repair the open wound. 
  • Failure to ensure staff implemented two-person assistance on a flat surface during ADL (activities of daily living) care which resulted in a hip fracture and surgery.

IJ/SSQC Level – F689 – Free of Accident, Hazards/Supervision/Devices

  • Failure to ensure a resident was supervised when going outside at 11:07 am which resulted in the resident having smoked unsupervised. The resident self-propelled his wheelchair from the facility and was stuck by a moving vehicle and sustained broken bones and internal injury that required surgical repair.
  • Failure to supervise a resident with a diagnosis of dementia for a resident reviewed for accidents which resulted in the resident exiting the facility, leaving the campus property, and walking to a nearby store on the corner of a heavily congested traffic intersection without staff knowledge.
    • The immediate jeopardy began on 3/19 when the resident eloped from the facility.
  • Failure to ensure supervision and operation of a mechanical lift with 2 staff members. The practice resulted in the resident falling from the mechanical lift.  The resident sustained injury to his lower spine and experienced pain.
    • The immediate jeopardy began when the resident sustained a fall with injury vehicle being transferred from the bed to wheelchair with a mechanical lift.

 In close running for the most frequently cited federal tag is F686—Treatment/Services to Prevent/Heal Pressure Ulcer for the following G Level citations:

  • Failure to notify the physician or change the wound treatment to prevent the development and or worsening of a pressure ulcer for 2 residents reviewed for skin wounds. This practice resulted in debridement, osteomyelitis and removal of the resident’s coccyx (coccygectomy).
  • Failure to ensure resident were provide the care and services related to treatments and interventions, to prevent the development of an unstageable pressure ulcer and deep tissue injury for 2 residents.
  • Failure to prevent the development of pressure ulcers on a dependent resident with a history of pressure ulcers, resulting in discovering an unstageable pressure ulcer with slough present and deep tissue pressure ulcers on the left heel, and pressure ulcer on the right heel.
  • Failure to ensure a resident received skin assessments and timely pressure ulcer treatments for 3 pressure ulcers, as ordered by the physician. This practice resulted in increased size and advanced stages of all pressure ulcers. 

Quality of Care was cited a total of three (3) times at the G Level for the following:

  • Failure to ensure a resident was treated appropriately for scabies
  • Failure to ensure treatment for cellulitis was ordered and implemented as ordered. This resulted in harm when the resident experienced increased pain and acquired open wounds to bilateral lower extremities.  The facility failed to ensure assessments were completed for a surgical wound, treatment orders were in place and documentation of treatments completed for a resident with right hip incision not resulting in harm but with a potential for harm.
  • Failure to call 911, as requested by the Power of Attorney for a resident. The resident displayed significant changes from baseline.

Other IJ/SSQC citations as follows: 

  • F600 (2 times)
  • F610 (1 time).

 Other G level citations as follows: 

  • F760 (1 time)
  • F690 (1 time)
  • F757 (1 time)

The Top Tag Webinar will be scheduled soon, and details and prevention strategies will be provided. For information or assistance, email ldavenport@ihca.org