The Indiana Department of Health conducted forty-three (43) recertification surveys in the month of July 2024 with the following outcomes:
- 4- G Level Citations
- 1 SSQC/IJ Citation
- 3 or 6.98% Deficiency Free Surveys
G-Level citation as follows:
F 686 (2 times) – Treatment/Services to Prevent/Heal Pressure Ulcer
- Based on interview and record review, the facility failed to prevent unstageable pressure ulcers from developing and failed to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing on the bilateral heels of a resident who was admitted without pressure ulcers, for 1 of 3 residents reviewed for pressure ulcers.
- Based on interview and record review, the facility failed to ensure services were effectively provided for a resident admitted without pressure related skin impairment and identified to be at risk to develop pressure injuries, failed to prevent the development of a pressure injury for a resident reviewed for pressure injuries. This deficient practice resulted in Resident X developing a facility-acquired stage two pressure injury on the left buttock that deteriorated to an unstageable pressure injury with infection that required debridement twice, and facility-acquired stage two pressure injuries on the coccyx and right buttock, and a facility-acquired stage one pressure injury on the right hip. The resident required acute care treatment for wound infection and a new facility-acquired pressure was identified on the left upper buttock by hospital staff upon admission.
F689 (1 time) – Free of Accident Hazards/Supervision/Devices
- Based on observation, interview and record review, the facility failed to ensure staff effectively implemented fall prevention interventions while using an assistive device in the shower to prevent accidents. The deficient practice resulted in a resident experiencing a fall requiring hospitalization for a subarachnoid hemorrhage. The resident fell off a shower bed. The pins that held the side rails up on the shower bed were missing.
F742 (1 time) – Treatment/Services Mental/Psychosocial Concerns
- Based on record review and interview, the facility failed to provide personalized care and interventions for a resident with diagnosis of schizophrenia and behaviors for 1 of 5 resident reviewed for behavior management which resulted in the resident having resident to resident altercations with four cognitively impaired residents residing on the same locked unit. Using the reasonable person concept, the residents would have psychological harm of chronic or recurrent fear and anxiety from the physical actions of another resident throwing items at residents or physically hitting residents.
The SSQC/IJ Citation is as follows:
F678 (1 time) SSQC/IJ – Cardio-Pulmonary Resuscitation (CPR)
- Based on record review and interview, the facility failed to immediately initiate Cardiopulmonary Resuscitation in accordance with the resident’s advanced directives for 1 of 3 residents reviewed for facility discharge. This deficient practice resulted in CPR not being provided immediately when staff found the unresponsive resident and the resident died.
The Immediate Jeopardy began on 6/22/24, when staff identified Resident D was unresponsive and failed to immediately initiate CPR. The Immediate Jeopardy was removed on 7/13/24, 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.