A total of 18 recertification surveys were completed by the Indiana State Department of Health in the month of May and of those, six (33.33 %) were found to be deficiency free. Providers received a total 6 IJ’s and 5 SSQC citations as follows:
F600 IJ/SSQC (3 times) – Free from Abuse and Neglect
- Failed to ensure resident did not experience abuse by taunting, laughing at them, spinning them in a wheel chair, rough treatment by pushing down on the head, arms and shoulders, sitting them down roughly by grabbing the back of the pants, and pulling the back of neck of the shirt over the wheelchair handle resulting in increased agitation and hospitalization. This also placed the resident at risk for choking and strangulation.
- Failed to ensure residents were able to communicate with the administrator without being verbally degraded and threatened with discharge from the facility which resulted with residents being tearful and indicating they felt like they lived in a prison rather than in their home.
- Failed to prevent resident to resident sexual abuse when two residents were touched sexually by another resident.
F610 IJ/SSQC (1 time) – Investigate/ Prevent/Correct Violations
- Failed to investigate resident to resident abuse to ensure further abuse was prevented.
F684 IJ/SSQC (1 time) – Quality of Care
- Failed to provide prompt medical care to a resident with a significant change in health and condition, that resulted in unresponsiveness, acute respiratory failure, and the need for the resident to be life lined from the acute hospital to another higher-level hospital.
F693 IJ/SSQC (1 time) – Tube Feeding management
- Failed to properly position a resident with a gastrostomy tube during care. The resident had a history of aspiration pneumonia and a recent hospitalization for aspiration pneumonia.
F760 IJ/SSQC (1 time) – Significant Medication Errors
- Failed to ensure resident was free from a transcription error of a significant medication. The resident developed mouth sores, low platelet counts, critical laboratory values, hospitalization and death.
K0100 IJ (1 time) – General Requirements – Other
- Failed to maintain an environment in accordance with NFPA 101, Life Safety Code (2012) Section 18.104.22.168. Section 22.214.171.124 states that all healthcare facilities shall be designed and constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. Documentation indicated the safety valve installed on a boiler was not rated to relieve the maximum energy that can be generated by the boiler.
The seven G level citations are as follows:
F689 (2 times) – Free from Accidents/Hazards/Supervision and Devices
- Failed to ensure residents were free of accidents. Supervision and effective interventions to prevent a resident from falling were not in place.
- Failed to ensure a resident’s wheelchair brakes were locked prior to the wheelchair rolling unattended, which resulted in a fall with a fracture to the humerus. Failed to provide incontinence care with two staff members resulting in a fall with a fractured great toe.
F692 (2 times) – Nutrition/Hydration Status
- Failed to ensure interventions were implemented. Weekly weights indicated significant weight loss and the physician was not notified.
- Failed to implement new interventions for a cognitively impaired resident with significant weight loss.
F760 (1 time) – Free from Significant Medication Errors
- Failed to ensure a resident did not receive another resident’s medication. The resident was admitted to the hospital with altered mental status.
F686 (1 time) – Treatment and Services to Prevent/Heal Pressure Ulcers
- Failed to ensure interventions and treatments for pressure ulcers were implemented.
F684 (1 time) – Quality of Care
- Failed to ensure care and treatment was provided in accordance with professional standards related to transportation to physician and pain clinic appointments not provided form two residents. Ongoing pain and emotional distress were the result of the missed appointments.
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