IJ/SSQC and G Level Citation Update for Skilled Nursing – April 2021

The Indiana Department of Health resumed the recertification survey process on April 12, 2021.  The IDOH conducted twenty-six (26) surveys, and of those, 4 or 15% were deficiency free.  Four nursing home providers received the following IJ/SSQC citations:

F689 J/SSQC (2 times) – Free of Accident Hazards/Supervision/Devices

• The facility failed to ensure a resident with dysphagia and at risk for choking received supervision while eating for 1 of 4 residents at risk for choking. This deficient practice resulted in the resident choking, coded and the emergency services being called, and the resident hospitalized. The resident later died on 4/8/2021. (Resident B).
  • The immediate jeopardy began on 4/5/21 when a Dietary Aide served Resident B a tray of food and left the resident with no assistance or supervision. The Administrator and Nurse Consultant were notified of the immediate jeopardy at 1:11 p.m. on April 9, 2021. The immediate jeopardy was removed on 4/11/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.
  • The resident had the following physician orders or other factors: mechanical soft diet with ground meat, Kennedy sups (a spill proof cup with lid) divided plate with meals and speech therapist to treat three times a week for oropharyngeal dysphagia treatment.  The resident was moderately cognitively impaired and required extensive assistance of one staff member for eating, and the care plan indicated the resident was at risk for aspiration related to diagnosis of dysphagia.
• The facility failed to ensure adequate supervision and interventions to prevent multiple falls for 2 of 3 residents reviewed for falls (Resident B and Resident C). This practice resulted in Resident B sustaining two hip fractures, a large acute right cerebral convexity subdural hematoma, with right to left shift of midline structures and a subarachnoid hemorrhage in the right temporoparietal region and Resident C sustaining a fracture to her right hip.
  • The immediate jeopardy began on 1/09/21 when Resident B fell and fractured her hip. She had experienced multiple falls previously and continued to fall with significant injuries including another hip fracture, head injuries and death, four days after her last fall, on 3/22/21. The Administrator was notified of the immediate jeopardy on 4/01/21 at 9:15 a.m. The immediate jeopardy was removed on 4/1/21 at 4:17 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

F686 J/SSQC (1 time) – Treatments to Prevent/Heal Pressure Ulcer

• The facility failed to prevent, and identify wounds prior to the stage being unidentifiable, and failed to ensure wound characteristics were documented, worsening of wounds were monitored, and treatment of wound regimens were updated for 1 of 3 residents reviewed for wounds. This resulted in sepsis, and hospitalization for Resident B.
  • The immediate jeopardy began on February 10, 2021 when the facility failed to prevent and identify wounds prior to stage being unidentifiable, failed to document wound characteristics, and failed to monitor worsening of wounds with update or treatment in wound regimen. The Regional Director of Clinical Services, Senior Director of Clinical Services, Regional Vice President of Operations, and Director of Nursing Services were notified of the immediate jeopardy at 2:15 p.m., on April 28, 2021. The immediate jeopardy was removed on April 29, 2021, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy.

F678 J/SSQC (1 time) – Cardio-Pulmonary Resuscitation

• The facility failed to provide continuous CPR to a resident until EMS arrived. The resident had an Advance Directive indicating the desire for CPR (full code status).  The staff ceased CPR and canceled the EMS call after CPR was initiated for 7 minutes, without an order from the Resident’s Physician, resulting in the death of a resident.
  • The immediate jeopardy began on 3/30/21 when two AN’s ceased CPR prior to EMS arriving at the facility and without a Physician’s Order and the resident expired.

F803 J/SSQC (1 time) – Menus Meet Resident ND/Prep in Adv/Followed

• The facility failed to ensure a resident with dysphagia and at risk for choking received a diet in the correct form for 1 of 4 residents reviewed for risk of choking. This deficient practice resulted in the resident choking, coding and the emergency services being called, and resident hospitalized.  The resident later died on 4/8/2021.
  • The immediate jeopardy began on 4/5/21 when a dietary Aide served Resident B a tray of food that was not in the correct form and left the resident to eat without supervision or assistance. The immediate jeopardy was removed on 4/11/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The top tag received at the G Level was F686 related to pressure ulcers. The G Level citation are as follows:

F686 (8 times) – Treatment/Services to Prevent/Heal Pressure Ulcer

• The facility failed to identify, assess, and treat a pressure wound on a resident’s right heel prior to discharge, resulting in harm when the resident had to have surgical intervention and debridement.
• The facility failed to ensure a resident’s plan of care was followed, which resulted in a stage 3 (full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to the right buttock, and to complete treatments as ordered by the physician.
• The facility failed to prevent pressure ulcers and follow physician’s orders for 4 of 4 residents reviewed for pressure ulcers. (Resident 27 and 34 with decreased mobility related to hip fractures developed unstageable wounds on the heels of their affected legs.
• The facility failed to ensure pressure ulcers were not acquired in the facility and wound treatments were implemented related to a Stage 3 pressure ulcer worsening to a Stage 4 pressure ulcer (Resident C), a Stage 2 pressure ulcer worsening to a Stage 3 pressure ulcer (Resident B) and failed to prevent a pressure ulcer for a resident who had a history of pressure ulcers (Resident D).
• The facility failed to ensure a resident who was admitted with an open area received the necessary treatment and services to promote healing related to the lack of treatment, assessment and monitoring which resulted in an unstageable pressure ulcer 4 days later. The facility also failed to assess and obtain treatments for pressure ulcers in a timely manner for 3 of 5 residents reviewed for pressure ulcers.
• The facility failed to ensure residents who were admitted with open areas and at risk for further pressure sore development, received the necessary treatment and services to prevent pressure ulcers related to lack of treatment, assessment, and monitoring for 2 of 3 residents reviewed for pressure ulcers. (Resident D & C). This resulted in a second unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer developing from a leg brace for a resident who had already acquired an unstageable pressure ulcer from the leg brace.
• The facility failed to implement specific interventions for a resident who was at risk for pressure ulcers. Resident B had a Stage III (subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed) sacral pressure ulcer.  (Resident B)
• The facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers related to not routinely repositioning a dependent resident. This resulted in the development of 2 Deep Tissue Injury (DTI) ulcers.

F689 (3 times) – Free of Accident Hazards/Supervision/Devices

• The facility failed to provide adequate supervision to prevent falls for 2 of 27 residents reviewed and failed to implement personalized interventions to prevent falls for 1 of 7 residents reviewed. This resulted in two residents sustain a hip fracture.
• The facility failed to implement adequate supervision and specific interventions for a resident who was identified as a fall risk. The resident had an unwitnessed fall that resulted in a laceration to the forehead that required sutures and a cervical (CS) fracture.
• The facility failed to provide adequate supervision to prevent accidents for a resident who was identified at risk for falling. The resident had an unwitnessed fall on the day of his admission, requiring hospitalization where he was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).

F600 (2 times) – Free from Abuse and neglect

• The facility failed to ensure a resident was free from physical and verbal abuse resulting in an immediate change of behavior. Using the reasonable person concept, it is likely this would lead to recurrent fear, anxiety, or depression.  A staff member witnessed another staff member slapping (1 time) a resident that was cognitively impaired.
• The facility failed to help with Activities of Daily Living in a timely manner related to assistance with bowel elimination. This resulted in a resident with urgency using a wastebasket to defecate, causing emotional embarrassment and humiliation.

F692 (2 times) – Nutrition/Hydration Status maintenance

• The facility failed to ensure residents maintained acceptable parameters of nutritional status related to assistance with meals, meal consumption records not completed, supplements discontinued and/or not provided and weights not obtained for residents who were nutritionally at risk, which resulted in a significant weight loss and potential for weight loss for 6 residents.

F760 (1 time) — Free of Significant Medication Errors

• The facility failed to ensure a resident reviewed was free of medication errors and resulted in the resident experiencing a seizure, requiring hospitalization.
  • Resident diagnosis included generalized epilepsy and was prescribed Lacosamide (an antiepileptic medication.
  • Medication Administration Record indicated no documentation on the record to indicate that the resident received the medication (Lacosamide) for 12 doses.
  • Resident did receive Depakote as ordered by the physician.

F867 (1 time) – QAPI/QAA Improvement Activities

• The facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the severity and number of deficiencies cited involving quality of care for nutrition, sufficient and competent nursing staff, RN coverage, resident rights for visitation and dignity, labeling and storage of drugs, kitchen sanitation and food safety requirements, infection control and employing a qualified Infection Preventionist. This practice affected 22 of 22 residents residing in the facility and resulted in harm for Resident 9 and Resident 15, who experienced significant weight loss.

For assistance and or question, please email ldavenport@ihca.org