July 6th Skilled Nursing Citation Update for G, SSQC/IJ Level Deficiencies

The Indiana State Department of Health conducted 44 recertification surveys in May and of those, none were found to be deficiency free.  Seventeen (17) providers received twenty-three (23) G Level citations and Three (3) providers received three (3) SSQC/IJ citations.

The G Level Citations are as follows:

Tag 689 (7 times) – Free of Accident hazards/Supervision/Devices

• Failure to ensure a Resident, who utilized a wheelchair as her main mode of transportation, was properly secured in the facilities transportation bus, while being transported to and from an appointment, resulting in the resident sliding out of the wheelchair onto the floor of the bus and fracturing her ankle when the bus driver had to break hard to avoid an accident. This deficient practice affected 1 of 1 resident reviewed for accidents. (Resident C)
• Failure to ensure two staff provided care to a dependent resident which resulted in the resident having rolled out of bed during care and sustained a fracture for 1 of 5 residents reviewed for falls.
• Failure to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls and who wandered resulting in two unwitnessed falls with injury that required acute care medical intervention for 1 of 6 residents reviewed for accidents. The facility failed to ensure implementation of a fall care plan intervention for 1 of 6 residents reviewed for accidents, and the facility failed to ensure full sharps containers kept in a soiled utility room were inaccessible, an unlocked and unattended lab cart containing syringe needles was inaccessible, an unlocked and unattended treatment cart containing syringe needles was inaccessible, and toilet bowel cleaner and surface cleaner were inaccessible for 5 independently and cognitively impaired ambulatory (mobile) residents of 25 residents residing on the 300 and 400 units.
• Failure to provide supervision to prevent repeated falls for a resident assessed to be at risk for falls that resulted in a fall with a left hip fracture and falls with bruises for 1 of 5 residents reviewed for accidents and, the facility failed to ensure a remote-control cord for a bed was free from disrepair for 1 of 1 randomly observed resident.
• Failure to ensure supervision to prevent repeated falls for residents assessed to be a high risk for falls and who wandered resulting in unwitnessed falls that resulted in rib fractures, lacerations, and skin tears for 2 of 5 residents reviewed for accidents.
• Failure to ensure adequate supervision and interventions were in place to prevent multiple falls for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident B sustaining multiple rib fractures, pain, and hospitalization.
• Failure to adequately supervise and implement effective interventions for 1 of 3 residents who were fall risks. Resident C acquired a fractured fibula related to a fall, after having had multiple falls with interventions that were not effective with his cognitive status, and increased confusion and impulsivity.

Tag 686 (4 times) – Treatments/Services to Prevent/Heal Pressure Ulcer

• Failure to prevent pressure ulcers, complete assessments, correctly stage, and follow physician’s orders resulting in a resident acquiring two Stage 3 pressure ulcers (Resident 59) and an Unstageable pressure for 3 of 7 residents reviewed for pressure ulcers.
• Failure to ensure interventions and treatments for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) were implemented for 1 of 9 residents reviewed for pressure ulcers resulting in harm when a resident developed an avoidable unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer on the left heel that worsened to a stage four (a sore that extends below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments; in more severe cases, they can extend as far down as the cartilage or bone), and developed an avoidable unstageable pressure ulcer to the right heel (Resident J). The facility failed to ensure documented interventions for refusal of wound care not resulting in harm but potential for harm for 1 of 9 residents reviewed for pressure ulcers.
• Failure to prevent the development of pressure areas and/or ensure residents with pressure areas received necessary treatment to promote the healing of pressure areas for 2 of 3 residents reviewed for pressure ulcers. Resident E did not receive catheter care that resulted in the development of an infected unstageable pressure area resulting in a hospital visit and antibiotic treatment given IM (Intramuscular) for 5 days.
• Failure to ensure appropriate and current interventions were implemented to prevent pressure ulcers which resulted in a resident (Resident G) acquiring a stage 3 (full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to the left buttock and a resident (Resident F) acquiring a stage 2 (partial thickness skin loss involving the epidermis, dermis, or both) pressure ulcer to the left buttock and an unstageable (full thickness loss in which the base of the ulcer is covered) pressure ulcer to the left heel and ball of the left foot, for 2 of 3 residents reviewed for pressure ulcers.

Tag 684 (2 times) – Quality of Care

• Failure to monitor a resident’s toe as ordered and obtain a venous Doppler ultrasound timely that resulted in a hospitalization with the need for surgical intervention for a necrotic toe for 1 of 2 residents reviewed for hospitalization, provide a wound dressing as ordered for 1 of 2 residents reviewed for wounds, and ensure a resident received care in accordance with physician’s orders to monitor weight daily and notify a physician of weight changes based on the physician’s orders for 1 of 1 resident reviewed for nutrition.
• Failure to ensure a resident’s legal guardian was immediately notified of a fall with injuries when the resident, who was unable to make decisions for herself, was refusing to go to the emergency room which resulted in actual harm when emergency medical treatment was delayed for the multiple areas of bleeding in the brain , a subdural hematoma (a type of bleed that occurs within the skull of head but outside the actual brain tissue), and arm fracture for 1 of 5 residents reviewed for falls.

Tag 690 (2 times) – Bowel/Bladder Incontinence, Catheter, UTI

• Failure to prevent the development of urinary catheter related infections for 2 of 2 residents reviewed for catheter care. Resident D with a suprapubic catheter developed a urinary tract infection (UTI) that led to hospitalization and required IV (intravenous) antibiotics, and Resident E with a Foley catheter developed catheter related unstageable wound that became infected and required a hospital visit, IM (intramuscular) antibiotics for 5 days due to a lack of or improper catheter care.
• Failure to notify the physician and obtain an order to catheterize a resident, based on the recommendations from the psychiatric team who had previously treated the resident, resulting in increased agitation, physical aggression, sleeplessness, pacing, and exit seeking. The resident was transferred to the hospital, while in the emergency room the resident received an antipsychotic medication by intramuscular injection, received an antianxiety medication, the resident received a urinary catheterization, and 500 cc of urine was returned. This affected 1 of 3 residents reviewed for bladder function, in a sample of 5.

Tag 725 (2 times) – Sufficient Nursing Staff

• Failure to provide sufficient staffing to provide adequate supervision to prevent falls which resulted in injury for 2 of 6 residents reviewed for accidents.
• Failure to provide sufficient staffing to provide adequate supervision to prevent repeated falls which resulted in major injury for 1 of 6 residents reviewed for accidents.

Tag 697 (2 times) – Pain Management

• Failure to ensure a resident was adequately medicated for pain prior to and during dressing changes with extensive wounds that required daily dressing changes for 1 of 1 resident reviewed for pain, resulting in the resident having increased anxiety and pain prior to and during dressing changes.
• Failure to provide effective pain management in accordance with the resident’s comprehensive care plan for 1 of 3 cognitively impaired residents reviewed experiencing pain. This resulted in a resident having impaired mobility, mood, poor quality of life and increased the risk of pressure ulcers.

Tag 692 (1 time) — Nutrition/Hydration Status Maintenance

• Failure to ensure physician orders were followed for a gastrostomy tube, physician and family notification, obtain weights, and address significant weight loss of 1 of 4 residents reviewed nutrition resulting in harm when the resident had a significant weight loss of 10% in 3 months, and failed to ensure physician and family notification, obtain weights, and address significant weight loss of 1 of 4 residents reviewed for nutrition resulting I harm when a resident had a significant weight loss for 1 of 4 residents reviewed for nutrition resulting in harm when the resident had a significant weight loss of 29% in 7 months.

Tag 600 (1 time) – Free from Abuse and neglect

• Failure to ensure a resident did not abuse another resident resulting in harm when Resident F’s verbal abuse escalated to physical abuse. Resident E received a reddened area to his face and a cut on his hand, and feared Resident F. The facility failed to prevent sexual abuse and psychological harm for a resident who was sexually assaulted by another resident.

The following are the three (3) SSQC/IJ Level Citations:

Tag 689 — Free of Accident Hazards/Supervision/Devices

• Failure to ensure residents received adequate supervision: Windows were secure; staff were trained to prevent elopement and respond to actual elopement; codes to elopement alarms were not openly visible and family and police were notified of an elopement in a timely manner for 3 of 3 residents reviewed with wandering and exit seeking behaviors.  This failure resulted in a resident successfully exiting the secured dementia unit through a window.

The immediate jeopardy began on 4/26/21 when Resident C, who had Alzheimer’s dementia, severely impaired cognitive status, and exhibited exit seeking behaviors and verbalizations since admission on 4/14/21, was not monitored between 3:50 a.m. and 5:00 a.m., when she was found to have exited through another resident’s window.  The facility notified the family and police after 6:00 a.m. (one hour later). The resident knocked on a stranger’s door 1.1 miles away.  The stranger called the police at 4:20 a.m.

Tag 686 — Treatment/Services to Prevent/Heal Pressure Ulcer

• Failure to ensure thorough assessments, interventions and treatments were implemented timely for a resident identified as being high risk for developing pressure ulcers who developed two State 4 pressure ulcers to the sacrum and additional pressure

ulcers to both heels, resulting in the resident having wound pain and fears of wound pain with toileting, depression, and requiring hospitalization for wound care and severe UTI.

The immediate jeopardy began on 1/3/21 when Resident W was noted to have shallow open areas on her buttocks, and the facility failed to notify the physician, assess, monitor, and obtain treatment for the open areas timely which resulted in development of unstageable ulcers.

Tag 600 – Free from Abuse and neglect

• Failure to ensure effective interventions to prevent a delay in staff notification, action, assessment, and medical care for a resident having pain, shortness of breath, and numbness on the left side, resulting in the resident having no pulse, being unresponsive, and death.

The immediate jeopardy began on 5/5/21 when a cognitively intact male resident, notified the Dietary Manager, her was short of breath and had pain down his left side.  The Dietary Manager notified two Licensed Practical Nurses.  Neither nurse assessed the resident util he was found face down in the floor.

Please forward questions to ldavenort@ihca.org