Skilled Nursing Facility Citation Update: G Level, SSQC & IJ’s (February)

The Indiana State Department of Health conducted forty-eight (48) recertification surveys in February and of those three (3) were deficiency free.  

There was one (1) Immediate Jeopardy/SSQC citation as follows:  

Tag F686 (1 time) – Treatment/Services to Prevent/Heal Pressure Ulcers 

• The facility failed to provide necessary treatment for pressure ulcers, and this resulted in worsening pressure ulcer conditions for a resident. The Pressure ulcer progressed from a Stage 2 on admission (per admission assessment documented in the clinical record) to a State 4.  

• The pressure ulcer required specialized treatment and surgical procedure.  

• The resident’s diagnosis included paraplegia and chronic wounds/ulcers. 

• Progress notes did not show communication related to worsening skin condition and the physician was not documented as notified timely of changes of condition related to pressure ulcers.  

The Immediate Jeopardy was called when the facility identified a wound to the coccyx upon admission and failed to notify the physician and obtain immediate treatment orders which placed the resident in immediate jeopardy of serious harm. 

The deficient practice was corrected prior to the survey and therefore past noncompliance.  

There were seven (7) G Level citations as follows: 

F686 (3 times) – Treatment/Services to Prevent/Heal Pressure Ulcers  

Facility #1  

The facility failed to prevent and/or properly treat residents for pressure ulcers.  

Resident A was admitted with diagnosis of diabetes and malnutrition and was assessed to be at a mild risk for pressure ulcers.  

• Developed a Stage 3 pressure ulcer on sacrum. There was notable delay in treatment and documentation had gaps.  

• The physicians order for treatment was not followed consistently and the facility policy for pressure ulcers was not available to the surveyors.  

Resident B was admitted with diagnosis of malnutrition and muscle weakness and assessed to be at risk for pressure ulcers. The resident did not have pressure ulcers during admission.  

• The resident developed an unstageable wound to the left heel and foot.  

• Treatment was not administered timely and weekly skin assessments were not documented consistently in the medical record.  

• The physician ordered treatment was not administered consistently as ordered.  

Facility #2  

The facility failed to ensure necessary treatment and services were provided to prevent and/or promote healing of facility acquired pressure injuries. Specific care plans were not developed, physician treatment orders and/or interventions were not followed, and assessments were not completed accurately. This resulted in the development of a facility acquired State 3 and Stage 4 pressure ulcers.  

Facility #3  

The facility failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident who had multiple health conditions including diabetes mellitus, quadriplegia, and dependent on a ventilator. The facility did not follow through with necessary wound care recommendations.  

F689 (1 time) – Free of Accident Hazard/Supervision/Devices  

The facility failed to prevent falls. Following falls, care plans were not updated with interventions to prevent further falls and residents’ environment was not free of hazards which resulted in a fall with fractures.  

• Diagnosis of resident was fractures of lower end right femur, cellulitis of Left lower limb, obesity, muscle weakness, and need for assistance with personal care.  

• Resident Foley Catheter Bag leaked onto the floor and staff wiped most of the urine up with a towel, but the floor was still wet. Resident warned staff that floor was wet, but staff insisted that the floor was dry. Resident slipped in urine on floor while staff assisted with transfer.  

F684 (1 time) – Quality of Care  

The facility failed to provide medication for cancer as ordered and did not arrange for residents to follow-up with oncologist appointments that were scheduled. The Medical Director did not collaborate with the resident’s oncologist before changing medications that resulted in a resident having no follow up oncology care to prevent further spread of metastases to the bone related to prostate cancer.  

F600 (1 time) – Free from Abuse and Neglect  

The facility failed to ensure a resident was not neglected and the facility failed to complete interventions in place to prevent neglect and abuse. This practice resulted in a resident observed to be extensively incontinent of urine and bowel movement including clothing, bed pad, sheet, blanket and had not received incontinent care for an undetermined amount of time.  

• The resident said he had not been provided with incontinent care since yesterday. 

• The physician ordered that the resident was to be offered toileting at 12AM, 5 AM, 8 AM, 12 PM, 3PM, 5:30 PM and at bedtime.  

• MDS indicated that the resident required moderate assistance with toileting and transfers.  

• Care Plans indicated that the resident required up to two staff for participation with toileting as needed and that the resident was at risk of a skin breakdown.  

F725 (1 time) – Sufficient Nursing Staff  

The facility failed to ensure that there were staff available to provide care in a timely manner for residents who required assistance.  

• A resident was observed to be visibly soiled of urine and bowel movement. He was saturated (pull-up, bed pad, bed linens, and blankets. The resident was to be on a toileting scheduled and documentation indicated he had not been offered toileting as ordered by the physician.  

• A resident did not have her call light answered timely to have care needs met.  

• Posted staffing indicated that there were 2 CNAs for thirty-nine residents.  

• Staff interviews indicated that assignments could not be completed as assigned with two CNA’s but could if there were three scheduled.