A total of 50 recertification surveys were completed by the Indiana State Department of Health in the month of June and of those, one (2.00 %) were found to be deficiency free. Providers received a total 17 G level citations and four providers received a total of 5 IJ’s and of those four were SSQC citations. The G level citations as follows:
F689 (6 times) – Free of Accidents Hazards/Supervision/Devices
- Failure to provide supervision and assistance to prevent accidents for 6 residents reviewed. The deficit practice resulted in 2 residents having falls with fracture injuries and 4 resident that smoked.
- Failed to ensure an x-ray was obtained timely after increased complaints of pain for a resident after a fall, and for not notifying the physician timely of an acute hip fracture, resulting in a delay of treatment for a resident who fell and sustained a fractured femur.
- Failed to provide supervision and assistance to prevent accidents for a resident reviewed for falls. Supervision and effective fall interventions were not in place for a resident, which resulted in a resident receiving a femur fracture and surgical intervention.
- Failure to ensure mechanical lift equipment was properly stored which resulted in a cognitively impaired and high risk for fall resident having fallen and sustained a large forehead laceration that required eleven sutures for closure. The facility also failed to provide supervision for a resident threatening and with means to harm herself.
- Failure to provide adequate assistance to prevent a fall with injury and failed to ensure post fall assessments were complete. This resulted in a fall and sustained fracture to a resident left hip.
- Failed to provide adequate assistance to prevent falls for 2 residents. The deficient practice resulted in a resident sustaining a fracture of her left hip and another resident sustaining a head laceration requiring staples.
F686 (5 times) – Treatment / Services to Prevent/Heal Pressure Ulcer
- Failure to ensure that heels were off loaded, and heel protectors were being utilized and monitored for use. This resulted in harm when the resident acquired pressure ulcer deteriorated from a calloused area to a stage 4 pressure ulcer.
- Failure to prevent the development and/or worsening of a pressure ulcer for 2 residents reviewed. This resulted in debridement, osteomyelitis and amputation for a resident and debridement, osteomyelitis and negative pressure wound therapy for another resident.
- Failure to re-evaluate a treatment plan to determine whether the current treatment needed to be modified in which a pressure injury deemed to have worsened and later resulted in hospitalization.
- Failure to ensure that pressure ulcers were assessed weekly and treatments were completed as ordered by the physician resulting in the worsening and infection of an unstageable pressure ulcer for 2 residents.
- Failure to ensure that residents with impaired mobility, did not develop pressure wounds for 2 residents reviewed for pressure wounds. The facility also failed to implement pressure ulcer interventions for another resident. This deficient practice resulted in residents developing unstageable pressure ulcers to the heels.
F725 (1 time) – Sufficient Nursing Staff
- Failure to ensure there were adequate and competent staff to provide nursing care to meet the needs of the residents including provisions of bathing, toileting assistance, oral care, feeding assistance, restorative services, wound care and pressure ulcer prevention.
F760 (1 time) – Free of Significant Medication Errors
- Failure to provide medication as ordered by the physician for a resident. A resident did not receive an as needed (PRN) medication for seizure activity. The medication was to be administered if the resident had seizure activity. Resident was transferred to the hospital Emergency Room and while she was in route to the hospital the paramedical team administered medication for seizure activity, which stopped the seizure activity. Resident was admitted to the hospital.
F700 (1time) – Bedrails
- Failure to ensure ongoing assessment for a change in condition for the use of side rails of a dependent resident which resulted in a resident with side rail entrapment, a fall, and a fracture of the resident’s right arm.
F692 (1 time) – Nutrition/Hydration Status Maintenance
- Failure to ensure dietary recommendations were implemented for a resident.
F684 (1 time) – Quality of Care
- Failure to turn and reposition the resident, monitor and implement interventions, which resulted in reoccurrence of severe excoriation and subsequent bleeding of a resident.
F600 (1 time) – Free from Abuse and Neglect
- Failure to prevent sexual abuse between two residents. A resident touched another resident inappropriately in the genital area resulting in psychosocial harm to a resident. The resident was blind and unable to see surroundings, resulting in tearfulness and ager for several day.
IJ/SSQC citations are as follows:
F689 IJ/SSQC — (2 times) – Free of Accidents/Hazards/Supervision and Devices
- Failure to ensure a resident with severe cognitive impairment, who was identified as a high risk for elopement and resided on a secure unit, did not leave the building unattended.
- Failure to ensure adequate supervision was in place when a resident who resided on
F686 IJ/SSQC — (1 time) – Treatment Services to Prevent/Heal Pressure Ulcers
- Failure to ensure pressure ulcers were not acquired in the facility and identified at greater than a Stage 2, failed to complete assessments, follow-up on progression of wounds, and send to wound clinic timely for assessment, treatment and follow-up.
F610 IJ/SSQC – (1 time) – Free from Abuse and Neglect
- Failure to ensure an allegation of abuse, when a male resident was observed exposing his genitals to a cognitively impaired female resident, was promptly and thoroughly investigated.
F812 IJ – (1 time) – Food Procurement Store/Prepare/Serve- Sanitary
- Failure to ensure the meatloaf temperatures were obtained and meat was fully cooked prior to serving to residents. The IJ was called when the staff served undercooked (raw) meatloaf to residents
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