A total of 46 recertification surveys were completed by the Indiana State Department of Health in the month of July and of those, two (4.35%) were found to be deficiency free. Providers (16) received a total of 22 G level citations and six providers received a total of 7 SSQC/IJ level citations.
IJ/SSQ citations are as follows:
F689 IJ/SSQC (4 times) – Free of Accident Hazards/Supervision/Devices
- Failed to ensure water temperatures did not exceed 120 degrees Fahrenheit, in the main dining room, resident room bathroom sinks, and resident shower rooms.
- Failed to ensure adequate care and supervision was in place when a resident with dementia and a wander guard in place excited the building (evening), without supervision, through a side door between the assisted living dining room and hall and then ambulated 0.7 miles away from the facility before being found by a staff member.
- Failed to ensure adequate supervision was in place when a cognitively impaired resident with dementia and a wander guard in place exited the building, without supervision through a fire door exit door. The fire exit door alarm sounded for 4 minutes prior to a housekeeping staff member resetting the door alarm to turn it off without looking outside the door to ensure a resident did not exit the facility.
F686 IJ/SSQC (1 time) – Treatment Services to Prevent/Heal Pressure Ulcer
- Failed to ensure a resident who was admitted with intact skin did not develop multiple pressure ulcers, ranging from Stage 2 to unstageable, and provide treatments, follow physician orders for wound care, and complete timely skin assessments resulting in several total pressure ulcer wounds, including one unstageable and one Stage 3 wound to the left lower extremity and diagnosis of MRSA infection in the wound for 2 of 3 resident reviewed for pressure ulcers.
Recommended action to avoid citation under F868:
- Designate a licensed nurse to be the champion of the pressure injury prevention program.
- Ensure adequate training for your staff. Check out the upcoming Skin and Wound Management Cetification Course scheduled for September 23-27, 2019. Click here for more information.
F678 IJ/SSQC (1 time) – Cardio-Pulmonary Resuscitation (CPR)
- Failed to ensure residents’ choices of code status were documented consistently in the medical record and the physician was aware of the residents’ choices.
F584 IJ/SSQC (1 time) – Safe/Clean/Comfortable/Homelike Environment
- Failure to implement effective intervention in a timely manner to maintain resident room and common area temperatures at 81 degrees Fahrenheit or lower, placing residents at risk for adverse reactions to the high temperatures. Just outside the facility main entrance the temperature measured 100.2 degrees Fahrenheit.
G level citations as follows:
F689 (10 times) — Free of Accident Hazards/Supervision/Devices
- Failed to ensure adequate supervision and fall prevention interventions were provided for a dependent resident resulting in a fall from bed with a femur fracture and a fall from be resulting in a wrist sprain for 2 residents.
- Failed to implement, modify, and communicate fall interventions to address a resident’s planting of her feet while being assessed in her wheelchair, resulting in an emergency room visit requiring sutures.
- Failed to ensure supervision to prevent a resident from flushing his Peripherally Inserted Central Catheter (PICC). This resulted in harm when a resident was found unresponsive with his PICC disconnected and an empty syringe in his hand. The facility also failed to ensure fall prevention interventions were implemented for a resident.
- Failed to ensure a resident received adequate assistance to prevent accidents which resulted in the resident falling from bed and sustaining a fracture of the left femur.
- Failed to transfer a resident using the required number of staff which resulted in resident acquiring a fractured ankle.
- Failed to ensure residents received supervision and assistance to prevent accident for a resident. Supervision and effective fall interventions were not in place for a resident with eight falls within the past 3 months, which resulted in the resident receiving a compression fracture of the L1 vertebra.
- Failed to ensure resident who were a high risk for falls received adequate assistance and supervision as care planned to prevent falls, which resulted in multiple falls for 2 residents. Both falls resulted in injuries of fractured nasal bones, swelling and bruising.
- Failed to ensure foot pedals were in place when a resident was propelled in a wheelchair by a staff member. The fall resulted in a fall with a head laceration and 13 sutures.
- Failed to ensure the safety of a resident while being transferred. A resident was inappropriately transferred manually when the care plan indicated a mechanical lift.
- Failed to ensure a resident was transferred with a mechanical stand up lift according to the manufacturers directions and the resident’s plan of care to prevent accidents resulting in the resident sustaining a fracture.
F686 (5 times) – Treatments Services to Prevent/Heal Pressure Ulcer
- Failed to prevent the development of pressure ulcers for a resident. This resulted in harm when the resident developed abrasions to her right and left gluteal folds from the use of ill-fitting briefs, that worsened to a Stage 3 pressure ulcer.
- Failed to promote the prevention of a pressure ulcer resulting in the development of an unstageable pressure ulcer, provide monitoring and assure treatment for a pressure ulcer was completed as ordered by a physician.
- Failed to ensure a resident at risk for pressure ulcers did not develop pressure ulcers resulting in osteomyelitis.
- Failed to ensure a pressure ulcer was identified prior to being unstageable, failed to accurately and timely assess the pressure ulcer to prevent the decline in the pressure with increased depth and tunneling and failed to maintain infection control standards during a dressing change.
- Failed to prevent a resident who was at risk for skin breakdown from developing a Stage III pressure ulcer and to ensure interventions were in place for a resident who was admitted with pressure ulcers.
F600 (2 times) – Free from Abuse and Neglect
- Failed to ensure a resident was free from abuse by another resident which resulted in multiple skin tears, multiple bruises, and a hematoma.
- Failed to prevent a male resident with known sexual behaviors, from sexually assaulting two female residents which resulted in psychosocial harm for a resident when she stopped attending some of her favorite activities and isolated herself in her room due to being afraid of another resident.
F675 (1 time) – Quality of Live
- Failed to ensure a treatment approved by a physician was obtained for a resident who had a history of recurrent lower extremity wounds and recently obtained skin tear to her left lower extremity which resulted in a lack of daily skin observations and hospitalization for cellulitis requiring intravenous antibiotic therapy.
F608 (1 time) – Reporting of Reasonable Suspicion of a Crime
- Failed to report a reasonable suspicion of a crime after finding a resident decease with his Total Parenteral Nutrition disconnected from his Peripherally Inserted Central Catheter.
Tag 684 (1 time) – Quality Care
- Failed to ensure sound assessments and treatments were completed for 2 residents. One resident was admitted to the hospital with an infection and another resident experienced increased pain and worsening condition of the wound.
Tag 867 (1 time) – QAPI/QAA Improvement Activities
- Failed to appropriately implement plans of corrective actions to prevent previously cited harm level deficiencies related to wounds from reoccurring. This was evidenced by the number and seriousness of citations at this survey, and the previous investigation of complaints with findings.
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