The Indiana Department of Health conducted a total of forty (40) recertification surveys and of those three (3) or 7.50% were deficiency free.
There was a total of nine (9) G Level citations as follows:
Tag 689 (3 times) – Free of Accident Hazards/Supervision/Devices
- The facility failed to supervise adequately during care and ensure two staff were providing care for a dependent resident resulting in resident falling out of bed and sustaining 3 brain bleeds and 5 facial sutures.
The facility failed to have fall interventions of two assistive devices in place and failed to have call lights available for a resident who had sustained a fall with fracture.
This affected 2 of 4 residents reviewed for accidents.
- The facility failed to ensure dependent residents who required staff assistance with mobility and assistive devices, received adequate supervision and assistance to prevent falls and failed to ensure staff used a mechanical lift with assistance for 3 of 3 residents reviewed for accidents. This deficient practice resulted in Resident C being hospitalized for treatment of a blunt carotid artery occlusion injury and fractures of the neck, spine, left femur, and tow fractures of the right foot. This deficient practice resulted in Resident B receiving a laceration with sutures to the right top of his head and to the right elbow.
- The facility failed to ensure a resident was secured in the wheelchair following manufacturer recommendations during a van transport. This deficient practice resulted in the resident falling out of the wheelchair when a van driver applied the brakes and incurring a spinal injury.
Tag 744 (2 times) – Treatment/Services for Dementia
- The facility failed to ensure a resident with dementia received appropriate services for behaviors to address physically aggressive behaviors (Resident B) for 1 of 3 residents reviewed for behaviors and failed to ensure other residents (Residents C & D) were protected from a resident with behaviors. This deficient practice resulted in Resident D sustaining a head injury behind the ear and experiencing pain and Resident C feeling unsafe and verbalizing fearfulness.
- The facility failed to ensure services were provided to residents with dementia to prevent resident-to-resident altercations for 2 of 3 residents reviewed for dementia. (Resident C, Resident D) This practice resulted in Resident D experiencing a fall and sustaining an acute fracture of the right upper arm bone with moderate displacement and rotation.
Tag 684 (2 times) – Quality of Care
- The facility failed to prevent a non-pressure related wound from resting directly on the floor for 1 of 2 residents reviewed. This resulted in Resident E’s wound becoming infected and requiring antibiotics.
- The facility failed to ensure an unlicensed staff notified a licensed staff member that a dependent resident experienced a fall before transferring the resident from the floor to a wheelchair. This deficient practice resulted in the resident not being immediately assessed for injury by a licensed nurse and the resident experienced bilateral femur fractures.
Tag 600 (1 time) — Free from Abuse and Neglect
- The facility failed to ensure residents were free from physical abuse for 7 of 9 residents reviewed for resident-to-resident physical altercations perpetrated by Resident B. This deficient practice resulted in Resident C fearing for personal safety and Resident D sustaining an injury with pain behind the left ear.
Tag 580 (1 time) – Notify of Changes
- The facility failed to immediately notify the physician and resident representative for a resident’s change in condition and failed to notify the physician prior to administration of an antiplatelet medications after a resident fell with a head injury for 1 of 3 residents reviewed for accidents. This deficiency resulted in Resident B experiencing a delay in treatment for a large right subdural hematoma with midline shift (brain bleed with significant swelling).
There was a total of two SSAC/Immediate Jeopardy Citations as follows:
Tag 689 SSQC/IJ (1time) – Free of Accident Hazards/Supervision/Devices
- The facility failed to ensure a resident was effectively secured in the wheelchair following manufacturer recommendations during a van transport. This deficient practice resulted in the resident falling out of the wheelchair when a van driver applied the brakes and incurring a spinal injury.
The Immediate Jeopardy began on 1/3/24 when Resident Z slid out of his wheelchair during transport when the facility van made a sudden stop. A written statement by Resident indicated Van Driver was transporting him back to the facility when the driver slammed on his brakes causing the resident to slide forward and out of the wheelchair. His legs went “2 different directions” and he was “stuck and in pain” and could not get up. The Van Driver “grabbed me” and lifted him back into the chair. The resident alleged the van driver commented “we need to replace those” referring to the safety belts. The van driver asked if he wanted to go to the hospital, but he had not seen any obvious injuries, so he told the driver it was okay to take him back to the facility. When he returned to the facility, staff came to his room to assess and talk with him about the incident. He told them his back and leg hurt and requested an x-ray be done. Staff indicated they would get an order for the x-ray but were not sure if it would be completed and read that evening. The resident called his daughter who then transported him to the hospital where he was diagnosed with a compression fracture to his spine.
An investigation of the incident was provided by the Administrator on 1/29/24 at 9:52 A.M. He indicated he had interviewed the van driver about how he secured the resident in the van. Van Driver 3 indicated, after loading the resident and his wheelchair into the van, he secured the frame of the wheelchair with four straps-one for each corner of the wheelchair. He then secured the harness seatbelt and made sure it fit him snuggly, however the lap belt had not been utilized. The van driver indicated there were two additional straps which could be used for the wheelchair frame to keep the wheelchair in place, but he did not “normally use those”. Van Driver 3 secured the resident in the van the way he had been trained by the Maintenace Director to secure residents. The Administrator indicated Van Driver 3 had been terminated for unrelated issues but had the drivers written statement of the incident. The Administrator indicated there was not a facility policy regarding safety in the van nor was there a safety assessment to ensure resident safety while riding in the van.
Tag 600 SSQC/IJ (1 time) – Free from Abuse and Neglect
- The facility failed to ensure Resident B was free from staff-to-resident physical abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident B sustaining fourteen severe first-degree burns on an ear, a lip, the neck, the upper back, the breast, the abdomen, the bilateral thighs, the bilateral buttocks, and the perineal area.
The Immediate Jeopardy began when it was identified the resident had fourteen burns that were caused by a hair dryer. Resident B sustained burns in fourteen locations across her body, which included, but were not limited to her breasts, pubic area, bottom, back of the neck, ear, and mouth area.
An incident report to the IDOH indicated the resident was found with eleven raised circular areas upon skin inspection. During investigation of the skin issues, it was determined that the marks were burns.
During an interview, on 1/9/24 at 8:45 a.m., the DNS and the ED were in attendance. The ED indicated she received a call from the DNS, on 1/6/24, indicating Resident B had eleven circular areas found on her body. A reportable was sent to the Indiana Department of Health. They began their investigation. On 1/7/24, the DNS received a call from a staff member who indicated the circular areas on Resident B looked like a hair dryer made them. At that time, a white hair dryer was observed in the ED’s office with a large circle and a smaller inner circle with
eight lines connecting the large and smaller circles together. The DNS indicated the resident had been burned by the hair dryer on multiple areas of her body. The DNS showed a picture of one of the burned areas on the resident and it was observed to have a large circle with a smaller inner circle with eight lines connecting the large and smaller circles together just as the white hair dryer. The ED indicated once the residents’ daughter was with the resident, the resident indicated she was hurt with a hair dryer, by a middle-aged white female who was a little heavy with blonde hair. A housekeeper, a nurse who matched the description, and the CNA who gave the resident her shower, on 1/6/24, were all suspended on 1/8/24.
The Immediate Jeopardy was removed when the facility completed the following: Psychiatric services completed an assessment on the resident and screened Resident B for trauma. The resident was placed on 1:1 for comfort. All residents were interviewed for abuse and any residents who were not able to be interviewed had skin assessments completed. In-servicing on abuse and behaviors management was completed to all staff members. The ED met with the Resident Council President to discuss reporting concerns of abuse immediately and the ED will attend the next meeting with permission. All hair dryers were removed from the shower rooms. Nursing Management will make rounds daily to observe any new resident behaviors or new skin areas.
For questions or assistance contact ldavenport@ihca.org