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Date ArticleType
2/9/2020 Regulatory
G/IJ/SSQC Citation Update for December 2019

A total of 33 recertification surveys were completed by the Indiana State Department of Health in the month of December and of those, one (3.03%) found to be deficiency free. Providers (8) received a total of 12 G level citations and nine (5) providers received a total of 5 IJ/SSQC level citations. 

IJ/SSQC Level citations are as follows: 

F689 IJ/SSQC (4 times) – Free of Accident Hazards/Supervision/Device

  • Failed to provide adequate supervision, for a resident wearing a wander guard bracelet, which resulted in the resident being able to elope from the facility. The resident had a wander guard bracelet intact to the ankle and exited the facility without staff knowledge. Staff was unaware of the missing resident until the Fire Department informed the facility that they had the resident and was returning the resident to the facility. 

The Immediate Jeopardy began when the facility failed to ensure a resident with diagnosis of dementia with behavioral disturbance did not follow a visitor out of the facility’s locked and alarmed sliding door and a wander guard bracelet to the ankle. The resident was spotted by a concerned citizen who observed the resident falling and then dispatched a call to the Fire Department.  The resident was at an intersection of a street and a busy two-lane highway.  The resident was dressed in a pair of sweatpants, a sweater and a pair of shoes and it was 40 F. 

  • Failed to provide supervision to prevent elopement of a cognitively impaired resident at risk for elopement. The resident was found by police at around 6:00 p.m.  No interventions were in place and the resident eloped again on a later date.   The resident’s location was unknown by the facility.  The resident was located at a hospital approximately 30 miles away from the facility.

The Immediate Jeopardy began when a resident exited a bedroom window.  The resident was found by police over 3 miles away across several busy roads approximately 20 hours after staff noted the resident was missing.  The resident was taken to a local hospital and returned to the facility.  This incident was not reported.  The resident eloped again out the same bedroom window and the resident’s location was unknown by the staff.  The county APS was notified and later found confused and delusional and was in a hospital about 30 miles away from the facility in an adjoining state.

  • Failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, with a history of exit seeking behaviors, whose whereabouts were unknown until the resident was observed by a staff member that was off facility property. The facility also failed to accurately and completely investigate falls and obtain neurological assessments of residents following falls for 2 of 3 residents.

The resident was seen by the Activities Director to exit the building at the end of the hall, directly behind a visitor who had exited.  Staff immediately went outside, and the resident walked quickly to the right of the building and was by the edge of the parking lot by the road.   Staff called the resident’s name, and he did not stop walking.   The resident was easily redirected to come back inside the facility.  He stated he just wanted to take a walk outside. 

  • Failed to ensure a resident with a diagnosis of dementia and moderate cognitive impairment, who exhibited exit seeking behavior, did not elope from the facility. Resident exited the facility during the night shift and was found outside by a dumpster.  The resident’s whereabouts were unknown by the facility until alerted by an Assisted Living resident in another part of the facility. 

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

  • Failed to ensure a resident who was at risk for pressure ulcers and had current pressure ulcers, did not develop a stage 3 to the right calf, unstageable to left heel and stage 4 to lateral plantar foot, and provide treatments, assessments, follow physician orders for care of wounds, and complete timely skin assessments resulting in one stage 3 (unstageable) wound to right calf measuring 12 cm by 8 cm by 0.1 depth with 80% slough, left heel stage 3 (unstageable) 1 cm by 1 cm by 0.2 depth with 100% slough and left plantar stage 4 with tendon present 2 cm by 0.5 by 0.5 cm to 1 of 8 residents. The facility also failed to ensure residents with risk factors for skin breakdown did not develop multiple unstageable pressure ulcers for 4 of 8 residents. 

G Level Citations are as follows: 

F686 (3 times) – Treatment/Services to Prevent/Heal Pressure Ulcer

  • Failed to provide pressure ulcer care according to current professional standards of practice as evidenced by : Failure to develop a pressure ulcer policy that includes management of pressure ulcers pain; failure to develop person centered care plan which included interventions for management of pressure ulcer pain; and failure to assess pressure ulcer pain during activity, rest and prior to, during, and after wound care for two residents with pressure ulcers.
  • Failed to ensure appropriate interventions for pressure ulcers were implemented resulting in harm when a resident’s skin tear worsened to an unstageable with signs of infection and then a stage 3 pressure ulcer to the right buttock.
  • Failed to identify timely and prevent a stage 3 or 4 pressure ulcer that was identified as a shear, wh ich resulted in a stage 4 facility acquired pressure ulcer and failed to ensure treatments were administered as ordered by the physician for two residents. 

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

  • Failed to ensure the physician was notified of the unavailability of an anticonvulsant medication for a resident which resulted in seizure activity and hospitalization.
  • Failed to identify symptoms of change in condition for a resident with heart failure and edema and notify the doctor for treatment. The resident had significant changes in daily weight gains and losses prior to the resident’s heart stopping, and the resident needing cardiopulmonary resuscitation before being transferred and admitted to the hospital. 

F760 (2 times) – Residents Free from Significant Med Errors

  • Failed to ensure long acting psychotic medication was administered per physician orders. This resulted in increased behaviors and potential danger to self.  Medication Administration Record indicated that resident refused Risperdal Consta Suspension several times and there was no documentation or follow-up found in the medical record.
  • Failed to ensure a resident received an anticonvulsant medication as ordered by the by the hospital discharge physician, which resulted in hospitalization for a resident reviewed for significant medication errors.

F740 (1 time) – Behavioral Health Services

  • Failed to develop and implement a plan to manage behaviors for a resident. This resulted in a resident having feelings of self-harm and hospitalization. 

F867 (1 time) -- QAPI/QAA Improvement Activities

  • Failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity of deficiencies cited and to ensure quality assurance procedures were followed and plans of action implemented to prevent deficiencies from re-occurring. This affected five residents reviewed for pressure ulcers. Actual harm occurred when a resident developed unstageable   pressure ulcers. 

F698 (1 time) -- Dialysis

  • Failed to ensure a resident was successfully transported to dialysis appointments and follow-up on resident’s condition after not receiving dialysis, that resulted in a change in condition and hospitalization.

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

  • Failed to follow-up on urine specimen results and obtain an ordered urine specimen in a timely manner to diagnose and treat a Urinary Tract Infection. Resident had a 26-day delay in treatment for a UTI and died with a UTI listed as the cause of death. 

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

  • Failed to provide supervision to prevent recurrence of falls and failed to develop and implement interventions to prevent falls, for a resident. This resulted in a resident having two falls in one day and sustaining a non-survivable head injury. 

Please forward questions to ldavenport@ihca.org