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

The Indiana Department of Health conducted 53 Recertification Surveys and of those, two were deficiency free. There was a total of two G Level citations and no SSQC/Immediate Jeopardy citations for the month of October 2024.  

The G-Level citations are as follows:  

F760 – Resident are Free of Significant Medication Errors  

• The facility failed to clarify conflicting hospital discharge orders and previous medication orders for appropriate dosing of a blood pressure medication. This deficient practice resulted in a significant medication error which required a resident hospitalization for 1 of 3 residents reviewed for hospitalization.  
  • A resident was returning to the facility after hospitalization for sepsis, urinary tract infection and acute kidney injury.  
  • A hospital Discharge Documentation form was provided to the facility from the hospital for her readmission to the facility.  
  • The form listed lisinopril 20 milligrams, one-half tablet (10 mg) every day. There was another section of the form titled “Discharge Plan” which stated lisinopril 20 milligrams 40 milligrams equals two tablets daily.  
  • The Medication Administration Record indicated an order for lisinopril 40 milligrams, two tablets (80mg) were marked as administered to the resident for 2 days.  
  • On the third day the order was discontinued and a new order for lisinopril 40 milligrams, administer 10 milligrams once a day was written and was given.  
  • The resident became lethargic, could not keep her eyes open, her blood pressure continued to drop, and she had short breath. The resident was sent to the emergency room for evaluation.  

F689 – Free of Accident Hazards/Supervision/Devices  

• The facility failed to ensure mechanical lift straps were safe for use prior to a transfer of a dependent resident for 1 of 1 resident reviewed for falls. This deficient practice resulted in a strap breaking during a transfer, the resident falling from the lift, and the resident sustaining a lift femur fracture.  
• The investigation completed by the facility indicated two staff members were transferring the resident via mechanical lift. There were no tears or rips to the sling prior to starting the transfer. As staff started to lift the resident and move them, the blue strap on the left side broke and the resident’s leg hit the floor. The resident was lowered to the floor. As the resident was being unhooked from the mechanical sling pad, two more blue straps tore.  
• The facility also failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 2 of 4 floors throughout the facility.