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Date ArticleType
12/1/2019 Regulatory
G/IJ/SSQC Citation Update for Skilled Nursing Facilities October 2019

A total of 37 recertification surveys were completed by the Indiana State Department of Health in the month of October and of those, four (0%) were found to be deficiency free.  Providers (10) received a total of 15 G level citations and three providers received a total of 3 SSQC/IJ level citations. 

IJ/SSQ citations are as follows: 

F689 IJ/SSQC (1 times) – Free of Accident Hazards/Supervision/Devices

  • Failed to ensure a resident who was at risk for elopement, received the supervision to prevent elopement from the facility. The failure resulted in the resident being without supervision and climbing a wall/fence and crossing a busy road.  The immediate jeopardy was called when the resident left the third floor, coded the elevator to go to the first floor.  He then went through the activity room door, which was unlocked and then through the sunroom door, which was unlocked.  The resident then through a screen door to a courtyard where he climbed the fence/wall and left the property.  The resident was unaccounted for approximately 15 minutes. 

F690 IJ/SSQC (1 time) – Bowel/Bladder Incontinence, UTI

  • Failed to ensure medical interventions and monitoring was initiated after staff became aware of an anchored urinary catheter became dislodged for a resident with neurogenic bladder. This resulted in the resident being sent to the Emergency Department where a suprapubic catheter was inserted with return of 1 liter of purulent urine and requiring hospitalization for IV antibiotics and diagnosis of sepsis.  The immediate jeopardy was called when the catheter became dislodged, the resident’s physician was not notified, and no follow-up provided to prevent the development of a UTI.  The resident required hospitalization for sepsis. 

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

  • Failed to monitor the Vancomycin levels and follow-up with resident’s physician, resulting in continued multiple administrations of the medication with critically high blood levels and being admitted to the hospital with Vancomycin induced kidney failure requiring hemodialysis. The immediate jeopardy was called when a resident had a high Vancomycin level the facility was unaware of, resulting in her receiving her antibiotic for 8 days before being sent to the hospital with a critically high blood level and requiring hemodialysis for acute kidney failure for Vancomycin toxicity.

G level citations as follows:

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

  • Failed to ensure the safe transfer of a resident resulting in a fall with a hip fracture and failed to implement care plan interventions for a resident with a history of falls.
  • Failed to ensure staff utilized proper transfer techniques with a Hoyer lift and failed to document a post fall assessment of a resident who fell during a transfer resulting in fracture of the right tibia.
  • Failed to supervise a dementia resident at risk for falls when she was left alone in the shower room siting on a shower chair which resulted in a fractured left hip. The facility failed to supervise a resident with a history of falls, dementia and impulsive behavior while sitting in the dining room in a Broda chair. 

F686 (3 times) – Treatments and Services to Prevent/Heal Pressure Ulcers

  • Failed to assess and treat a stage 2 pressure ulcer timely, resulting in the progression of a stage 2 pressure area to an unstageable pressure area, failed to provide intervention to prevent an unstageable pressure area from developing and the facility failed to assess timely and consistently provide interventions to aid in healing and prevent further pressure areas to develop.
  • Failed to ensure multiple stage w pressure ulcers did not develop on a resident assessed at severe risk for pressure ulcer development and failed to ensure pressure ulcers were assessed and treatment interventions were implemented timely after a readmission to the facility. This resulted in deterioration in the pressure ulcers.  The facility also failed to assess and revise plan of care for pressure ulcers for 2 residents.
  • Failed to ensure interventions for the application of a below the knee prosthesis were communicated from the therapy department to the nursing department, and filed to complete daily skin assessments of the below the knee residual resulting in the resident developing unstageable pressure ulcer and infections (MRSA).

F580 (2 times) – Notify of Changes (Injury, Decline/Room, etc.)

  • Failed to notify the physician timely of a significant weight gain and changes in a respiratory status. Resident had a delay in physician ordered interventions for the respiratory symptoms and was hospitalized for acute pulmonary edema.
  • Failed to notify the physician of a resident’s complaint of pain and missing laboratory results which resulted in hospitalization with diagnosis of sepsis/septic shock due to a catheter UTI. The facility also failed to notify a resident responsible representative of 71 missing hydrocodone’s.

F684 (2 times) – Quality of Care

  • Failed to follow their policy for weekly skin assessments and monitoring for a resident with a wound to the top of her right foot, which resulted in a delay of treatment and the resident being hospitalized for acute cellulitis and maggots in between the toes of her right foot.
  • Failed to identify and implement interventions for a significant weight fain for a resident with a history of pulmonary edema and congestive heat failure.

F692 (2 times) – Nutrition/Hydration Status Maintenance

  • Failed to ensure timely interventions were in place to prevent weight loss for a resident. This resulted in severe weight loss of 8% in 30 days.
  • Failed to identify and respond to an assessed weight loss and failed to implement interventions for a dependent resident with weight loss which resulted in additional severe weight loss for that resident.

F690 (1 time) – Bowel/Bladder Incontinence, Catheter, UTI

  • Failed to assess and request medical intervention for a resident who complained of pain related to anchored catheter. The resident was hospitalized and diagnosed with sepsis related to a catheter UTI.

F770 (1 time) – Laboratory Services

  • Failed to obtain a urinalysis and culture and sensitivity sample in a timely manner for a resident. Resident was admitted to the hospital for a UTI and sepsis.

F867 (1 time) – QAPI/QAA Improvement Activities

  • Failed to identify issues and develop and implement appropriate plans of action in regard to the communication between therapy department and nursing department for goals and interventions and daily skin assessments prior to the application of the prosthesis, which resulted in a resident developing an unstageable pressure ulcer and an infection of MRSA to the residual limb.

Please forward your questions or requests for assistance with survey readiness to ldavenport@ihca.org