A total of 54 recertification surveys were completed by the Indiana State Department of Health in the month of August and of those, four (7.41%) were found to be deficiency free. Providers (21) received a total of 26 G level citations and four providers received a total of 4 SSQC/IJ level citations.
IJ/SSQ citations are as follows:
F689 IJ/SSQC (3 times) – Free of Accident Hazards/Supervision/Devices
- Failure to ensure adequate care and supervision was in place when a resident with dementia and a wander guard exited the building without supervision at 8:02 p.m. The resident exited through an unlocked and unsecured door on the dementia unit without staff knowledge. The resident ambulated 0.9 miles away from the facility and was found by a bystander located by a gas station and busy intersection. The speed limit in the area the resident was found was 30 miles per hour. The resident was transported in the bystander’s car after the bystander was able to contact the family. The resident was returned to the facility at 9:04 p.m. (Past Non-Compliance)
- Failure to ensure an assistive device was in safe functioning condition resulting in a Hoyer sling breaking during a transfer of a resident. This resulted in a resident having multiple fractures and lacerations. (Past Non-Compliance)
- Failure to ensure a cognitively impaired resident, with known elopement risk, received supervision to prevent elopement from the facility. The resident was observed to exit the facility by a housekeeping staff member who did not notify administration or nursing staff the resident was outside. The resident was found on the corner of a moderately traveled intersection. The resident exited the front door while the housekeeping staff member was cleaning the door. The door was in the open position. The residents wander guard was sounding and the alarm on the door was also sounding. The resident’s location was not known until a family member just happened to be traveling to the facility to visit and saw the resident 0.1 miles from the facility in her wheelchair.
F760 IJ/SSQC (1 time) – Residents are free of Significant Medication Errors
- Failure to ensure a significant medication error did not occur when a nursing student was not supervised by a staff nurse during medication administration and a resident was given another residents medication. This resulted in the hospitalization and intubation of a resident due to compromised ventilation.
G Level Citations are as follows:
F686 (9 times) – Treatments/Services to Prevent/Heal Pressure Ulcer
- Failure to ensure a pressure wound did not worsen from a stage 2 to the resident requiring hospitalization for osteomyelitis and gangrene of the 4th and 5th
- Failure to ensure a pressure ulcer was not acquired in the facility and wound treatments were completed related to a stage 2 pressure ulcer worsening to a stage 3 pressure ulcer for a resident.
- Failure to ensure pressure ulcers were not acquired in the facility related to Stage 3 and Stage 4 pressure ulcers and interventions and treatments were not in place for two residents.
- Failure to ensure appropriate interventions for pressure ulcers were implemented resulting in harm when a resident’s pressure ulcer on the coccyx worsened from a stage III (Full-thickness loss of skin, in which fat is visible in the ulcer) to unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by dead skin tissue) and increased in size, and the resident developed 3 additional pressure ulcers to include an unstageable pressure ulcer to right buttock, an unstageable pressure ulcer to the left ischial tuberosity (a rounded bone that extends from the curved bone that makes up the bottom of your pelvis called the ischium), and a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer to the right ischial tuberosity for a resident.
- Failure to implement measures to prevent an unstageable pressure injury from developing for a resident at known risk of pressure ulcer development, who developed a pressure ulcer that was not identified until it was an unstageable ulcer.
- Failure to implement pressure ulcer prevention and interventions, failed to implement the wound care physicians orders and the wound progressed from a Stage II to an unstageable pressure ulcer, with subsequent admission to the hospital for an infected pressure ulcer and failed to identify a pressure ulcer until it was an unstageable ulcer and failed to complete accurate and timely assessment for pressure ulcers for 3 residents.
- Failure to adequately monitor and assess, an at-risk resident with a known history of pressure ulcers, which resulted in actual harm when the resident redeveloped two pressure ulcers, on his buttocks, that were not identified until they had worsened to Stage III (Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia).
- Failure to ensure interventions and treatments for pressure ulcers were implemented. This practice resulted in harm when the resident developed a Stage I pressure ulcer on the coccyx that worsened to a Stage II and an unstageable pressure ulcer to the left heel. The facility failed to ensure care plans related to pressure ulcer prevention and care were implemented.
- Failure to prevent pressure ulcers from developing and failed to ensure pressure ulcers were identified at an early stage. Pressure ulcers worsened.
F689 (5 times) – Free of Accidents Hazards/Supervision and Devices
- Failure to provide supervision and effective interventions to prevent falls for a resident with a history of falls resulting in a fall with fracture.
- Failure to provide supervision and assistance to prevent accidents for two residents reviewed for falls. Supervision and fall interventions were not in place, which resulted in a fracture requiring surgical intervention. Resident also had facial injuries.
- Failure to ensure adequate supervision and assistance was provided to maintain safety related to residents needing assistance of two staff while being transferred and instead used a one-person transfer.
- Failure to ensure a resident was provided supervise on to prevent accidents related to a fall during a transfer that resulted in a right tibia.
- Failure to ensure adequate supervision to prevent a resident from having pushed another resident. This resulted in a fall with a hip fracture and surgery repair.
F692 (3 times) – Nutrition/Hydration Status Maintenance
- Failure to ensure weights were obta10.ined, interventions were implemented, and the physician and resident’s representative were notified of a severe weight loss resulting in a weight loss of 10.1 percent in 180 days.
- Failure to ensure a resident did not experience a significant weight loss. The facility failed to ensure the resident’s weight was monitored and new interventions were implemented when weight loss continued resulting in a weight loss of 8.44 percent in one month.
- Failure to identify and implement new interventions for a cognitively impaired resident who had a significant weight loss and continued to lose weight. The resident had a 5.66 percent weight loss in 30 days, then an additional weight loss of 4.28 percent in 38 days without nutritional intervention.
F690 (3 times) – Bowel/Bladder Incontinence
- Failure to ensure a resident had documented evidence of signs and symptoms to justify the use of an indwelling urinary catheter and provide urinary catheter care and treatment in the resident being hospitalized with a urinary tract infection.
- Failure to treat a UTI (urinary Tract Infection) appropriately and in a timely manner which resulted in a resident being transferred and admitted to the hospital with sepsis.
- Failure to follow through with a referral to a urologist for anchored catheter concerns for a resident with recurrent urinary tract infections. Resident was admitted to the hospital for sepsis syndrome secondary to the urinary tract infections. The facility failed to ensure the catheter remained off the ground to minimize the risk of infection for 2 residents.
F697 (2 times) – Pain management
- Failed to ensure residents were free from avoidable pain related to not providing an effective pain management program to include continued pain assessment, physician notification, altered interventions and follow-up resulting in ongoing excruciating pain which affected a resident’s psychological state and daily ability to function and the lack of timely administration of pain medication.
- Failure to provide pain medication for a resident who had a knee replacement resulting in extreme pain, tearfulness, inability to sleep and inability to get out of bed.
F867 (2 times) – QAPI/QAA Improvement Activities
- Failure to implement a system to identify and prevent the development of new pressure ulcers, ensure adequate staff to meet the needs of residents, and provide activities on weekends. This was evident by the seriousness of citation at this survey, and previous concerns.
- Failure to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity and number of deficiencies cited and to ensure quality procedures were followed and plans of action implemented to prevent deficiencies from reoccurring.
F760 (1 time) – Residents are Free of Significant Medication Errors
- Failure to ensure a medication was given per physician orders for a resident. The resident was administered too much Potassium Chloride over a period of time.
F605 (1 time) – Right to Be Free of Chemical Restraints
- Failure to ensure a resident was not given psychotropic medications to chemically restrain him. The resident was given multiple psychotropic medications and had multiple falls after medication implementation and had significant weight loss.
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