G/IJ/SSQC Citation Update for November 2019

G Level Citations mandate a sharp focus by providers in management of clinical programs.

A total of 59 recertification surveys were completed by the Indiana State Department of Health in the month of November and of those, one (2.56%) found to be deficiency free.  Providers (9) received a total of 11 G level citations and nine (9) providers received a total of 11 IJ level citations.

IJ/SSQC Level citations are as follows: 

F689 IJ/SSQC (5 times) – Free of Accident Hazards/Supervision/Devices

• The facility failed to ensure an elopement of a resident from the secured dementia unit did not occur for a resident reviewed for elopement. The resident who resided on the locked unit with a diagnosis of dementia with behavior disturbances, was assisted out of the locked front door of the secured unit by another resident’s family member.  The facility staff was not aware the resident was let out or was missing off the unit.  The resident had ambulated across the 4 lane moderately busy street to the field, by the hospital.  The resident was outside the facility for 30 minutes.
• The facility failed to ensure staff responded appropriately when an unlocked alarming exit door sounded resulting in a resident exiting the building with whereabouts unknown for approximately 3 hours for a resident reviewed for supervision. The resident was located off the facility property in a wooded area by the police and admitted to the hospital for hypothermia.
• The facility failed to ensure preventative interventions (utilizing an approved model of a Broda chair for transporting residents in a facility vehicle and following the appropriate user instructions for the facility’s latching/seat belt device system were in place to prevent a fall for a resident.
• The facility failed to use a gait belt during a transfer and failed to do a nursing assessment prior to moving the resident after failing. This practice resulted in a resident falling and sustaining an acute intracranial hemorrhage which resulted in death.
• The facility failed to ensure adequate supervision was in place when a cognitively impaired resident with exit seeking behaviors exited the building without staff knowledge, and was found by non-personnel with the back of his wheel chair wheels over the white line in the road of a high volume traffic area.

F600 IJ/SSQC (2 times) – (citation resulting in placement of the abuse icon on) – Free from Abuse and Neglect

• The facility failed to ensure verbal, physical and sexual abuse resident to resident sexual, physical, and verbal abuse did not occur with a repeated occurrence for 12 of 12 cognitively impaired residents. Interventions were not put into place to prevent occurrences.  Using the reasonable person concept, it is likely that this would lead to chronic or recurrent fear and anxiety.
• The facility failed to prevent staff to resident verbal and physical abuse for 2 of 3 residents reviewed for abuse.

F580 IJ (1 time) – Notify of Changes (Injury/Decline/Room, etc.)

• The facility failed to notify the physician when a resident had a fall with a head injury for a resident reviewed for accidents. The deficient practice resulted in a delay in treatment after a fall with head injury and death four days after.

F684 IJ/SSQC (1 time) – Quality of Care

• The facility failed to adequately monitor and document blood sugars for a resident reviewed for insulin. This resulted in the resident receiving a large amount of rapid-acting insulin, without documented indication, and without monitoring or assessment following the insulin administration and resident died the next morning after the administration.

F686 IJ/SSQC – K level – Treatments/Services to Prevent /Heal Pressure Ulcer

• The facility failed to prevent pressure ulcers, complete follow-up assessments, track wound progression, follow interventions, and notify the physician with worsening of wounds up to and including, infections for 5 residents reviewed for pressure ulcers. The resident’s Stage 2 progressed to an unstageable ulcer with a wound infection and another resident’s Stage 3 ulcer worsened to a Stage 4 with signs of infection.

F609 IJ/SSQC – Reporting of Alleged Violations

• The facility failed to ensure staff who witnessed verbal and physical abuse reported the alleged abuse to the facility Administrator per policy for 2 of 3 residents reviewed for abuse.

G Level citations are as follows: 

F692 (3 times) – Nutrition/Hydration Status Maintenance

• The facility failed to ensure fortified food interventions were implemented as recommended for resident who experienced severe weight loss of 18% within a 6-month period for a resident reviewed for nutrition.
• The facility failed to ensure identification of and implement treatment and services for assessed decreased protein levels and for gradual weight loss which resulted in severe weight loss for a resident reviewed for nutrition.
• The facility failed to ensure residents maintained acceptable parameters of nutrition related to not obtaining monthly weights, not providing additional supplements, and not collaborating with the dialysis center for two residents reviewed for nutrition. This resulted in a significant weight loss of greater than 5% in one month for a resident.  The facility also failed to provide liquids with meals for a resident reviewed for nutrition and hydration.

F744 (2 times) – Treatment/Services for Dementia

• The facility failed to adequately supervise and implement interventions for a resident with dementia that wanders in other residents’ rooms, who fell resulting in a hip fracture for a resident.
• The facility failed to adequately implement care planned interventions and strategies for a resident with wandering behaviors and diagnosis of dementia that resulted in a sexually inappropriate behaviors for 2 residents reviewed for dementia care.

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

• The facility failed to provide treatment and services for an indwelling urinary catheter to prevent the development of a urinary tract infection (UTI) and sepsis for a resident reviewed for urinary catheters.

F697 (1 time) – Pain Management

• The facility failed to ensure pain medication was administered timely and provided effective pain control for a resident with complaints of pain after a fall which resulted in a right femur fracture for a resident reviewed for pain medication.

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

• The facility failed to provide adequate supervision to prevent repeated falls, resulting in a scalp laceration requiring sutures for a resident reviewed for falls.

F684 (1 time) – Quality of Care

• The facility failed to provide wound care for a resident with a surgical incision for a resident reviewed for hospitalization. This resulted in the incision reopening requiring additional surgery and hospital stay for the resident.

Please forward questions or request for assistance with regulatory and clinical compliance to ldavenport@ihca.org