IHCA/INCAL

News

Click here to access archived news articles.

ARTICLE

Date ArticleType
2/29/2016 Regulatory
IJ/SSQC Citation Update

There were a total of 41 Recertification surveys conducted by the Indiana State Department of Health in the month of January and of those, 3 were found to be deficiency free. There were 21 G level Tags cited, with the top G level tags this month cited for F314 related to pressure sores, F323 related to resident safety and supervision, and F309 related to quality of care.

SSQ/IJ Update
There were 5 IJ with 4 SSQC citations, issued to five facilities by the ISHD in the month of January.

IJ citations for F323 are based on the following;

• Based on observation, interview, and record review, the facility failed to maintain water temperatures less than 120 degrees F (Fahrenheit) to prevent burns to kin in contact with the hot water from sinks in resident bathrooms. The facility had a Preventive Maintenance Program referenced in the 2567, that indicated residents room water temps are assessed on at least a quarterly basis.
• A resident was observed utilizing liquid oxygen. A small e-cylinder of oxygen was observed next to the room’s heating source. A large 41-liter liquid oxygen tank was next to that. The heating source was on and running. The facility provided the surveyors with a policy, referenced in the 2567, and the policy stated “Keep oxygen equipment and oxygen tubing at least 5 feet away from any heat source”.
• The hallway soiled utility room was observed unlocked with three bottles of cleaning chemicals in spray bottles on top of the hopper. With the Maintenance Supervisor the chemicals were identified as “Virex” “Biological Liquid Odor Control /Cleaner,” and an unlabeled bottle of blue liquid, later identified as glass cleaner.
• Housekeeping closet was observed to be unlocked. Several chemicals were observed sitting in the unlocked closet and residents were participating in an activity near the unlocked closet.

IJ citations for F223 are based on the following;

• Based on record review and interview the facility failed to ensure residents remained free of physical, verbal and emotional abuse related to a CNA spraying water on and using profanity towards a cognitively impaired dependent resident being sprayed with water. The CNA recorded a video of the resident in the shower, being sprayed with water. The video was posted on social media.
• Based on record review and interview, the facility failed to adequately monitor and supervise a resident who wondered into other resident rooms, attempting or engaging in non-consensual sexual interaction.

IJ citations for F314 are based on the following

• Based on observation, record review and interview, the facility failed to ensure residents at risk for pressure ulcer development received interventions to prevent pressure ulcers. The resident developed a stage 2 pressure ulcer that progressed to a stage 4, was then referred to the wound clinic. The wound failed to heal, and then required hospitalization for further treatment of the wound. Another resident was found with a stage 2 wound under a brace, and another resident acquired a stage 2 pressure ulcer on the right ear from unpadded oxygen tubing.

IJ citation for F 155 are based on the following;

• Based on interview and record review, the facility failed to follow a resident’s wishes (Advance Directives) to not be resuscitated (Do Not Resuscitate) (DNR) and failed to ensure staff accurately documented specific facts in the clinical record for residents reviewed for advanced directives. This resulted in a resident receiving life saving measures when respirations ceased, including intubation and administration of intraosseous (process of injecting directly into the bone morrow) medications.

IJ citations for F225 are based on the following;

• Based on record review and interview, the facility failed to ensure allegations of non-consensual sexual interaction were immediately reported and investigated for allegations of sexual misconduct. The 2567 references interview of the resident (#1), stating a resident (#2), on “five or six” different occasions, entered his room touching himself and attempted to “grope” him (resident #1). Resident #1 also indicated a report of the incidents where resident #2 entered resident #1’s room was made to third shift nurses, five different occasions.

IJ citation for F226 are based on the following;

• Based on record review and interview, the facility failed to ensure its policies were implemented to prevent a resident with wondering and inappropriate sexual behaviors from attempting or engaging in non-consensual sexual interactions with other residents and failed to ensure allegations of abuse were reported and thoroughly investigated for 2 of 7 residents reviewed for allegations of abuse.

If you would like more details, related to the citations listed above, please contact Lori Davenport
at ldavenport@ihca.org