The Indiana Department of Health conducted a total of forty-six (46) recertification surveys and of those one (1) or 2% was deficiency free in the month of February.
The G Level Citations are as follows:
Tag 684 (2 times) – Quality of Care
- The facility failed to ensure a resident, who received hospice services, was not over medicated and was assessed for the need of narcotic medication for 1 of 1 resident reviewed for Hospice and End of Life Services. The deficient practice resulted in Resident 4 becoming dehydrated, having urinary tract infections, scratching open a new wound on her chest, and being unable to communicate at her baseline.
The facility also failed to identify an injury of unknown origin and failed to accurately document the new skin area on the resident’s chest for 1 of 1 resident reviewed for Hospice and End of Life Services.
- The facility failed to ensure significant weight changes were identified and timely interventions were implemented for 2 of 5 residents reviewed for changes in weight. This deficient practice resulted in Resident 109 experiencing two events of significant weight gain which required hospitalization for fluid overload and Resident 19 experiencing significant weight loss which required hospitalization for altered mental status and dehydration.
Tag 689 (1time) — Free of Accident Hazards/Supervision/Devices
- The facility failed to ensure a cognitively impaired and dependent resident was safe from an injury of unknown origin. Failed to ensure a resident did not have vaping materials in the room and failed to prevent recuring falls for a resident who was identified as a high risk to experience falls for 3 of 3 residents reviewed for accidents. This deficient practice resulted in a resident sustaining a left arm fracture.
SSQC/ IJ Citations are as follows:
Tag 689 SSQC/IJ – Free of Accident Hazards/Supervision/Devices
- The facility failed to ensure adequate supervision was provided to prevent unsupervised smoking inside the facility and failed to ensure hazardous smoking material were not accessible to residents who required supervised smoking for 1 of 3 residents reviewed for smoking.
The Immediate Jeopardy began on 1/30/24 when Resident B was observed with cigarettes and lighter smoking in her room. Unsupervised smoking could result in fire or burn injury to herself and other residents residing in the facility.
Tag 684 SSQQC/IJ – Quality of Care
- The facility failed to ensure respiratory status was effectively assessed after a medication error for 1 of 3 residents reviewed for change of condition. This deficient practice resulted in a change in the resident’s condition and subsequent death.
The immediate jeopardy began on 2/16/ when Resident Q was administered MS Contin 30 mg that was not prescribed for her. The facility failed to adequately assess and monitor the resident for respiratory depression after identifying the medication error. This resulted in a change of condition and death of the resident.
F760 SSQC/IJ – Residents are Free of Significant Medication Errors
- The facility failed to ensure Resident Q did not receive an opioid medication that was ordered for another resident and failed to ensure Resident Q was effectively monitored for signs and symptoms of adverse reaction for 1 of 3 residents reviewed for significant medication errors. This practice resulted in Resident Q becoming unresponsive and the resident expired.
The Immediate Jeopardy began on 2/16 when resident Q was administered a MS Contin 30 mg tablet not prescribed for her. The facility failed to adequately assess and monitor the resident’s condition after identifying the medication error. This resulted in a change of condition and death of the resident.
Tag 803 IJ – Menus Meet Resident Needs/Prep in adv/Followed.
- The facility failed to ensure staff followed the physician order for a resident on a mechanical soft diet when the wrong texture of the diet was provided. The facility failed to aid with meals which resulted in a resident choking for 1 of 4 residents reviewed for dietary requirements.
The Immediate Jeopardy began on 1/24, when it was identified Resident B was provided a regular diet in place of a mechanical soft diet. Resident B choked on her dinner, was provided the Heimlich Maneuver, lost consciousness, and expired in the facility.
Direct questions to ldavenport@ihca.org.