SNF Citation Update – G Level, SSQC/IJ – September 2023

The Indiana Department of Health completed a total of 44 recertification surveys in the month of September 2023 and of those two (4.55%) were deficiency free. Twelve providers received thirteen G Level citations and one provider received an Immediate Jeopardy/SSQC citation. 

G Level Citation as follows:  

F689 – Free of Accidents Hazards/Supervision/Devices  

• The facility failed to revise care plans and follow interventions to reduce the risk of falls for 2 of 4 residents reviewed for accidents. This deficient practice resulted in a fall with factures requiring hospitalization and a fall with closed head injury requiring hospitalization.  
• The facility failed to protect a resident from injury while walking with the resident from the bathroom to the resident’s recliner without using a gait belt for 1 of 3 residents reviewed for accidents. Resident B fell and hit their head resulting in a laceration which was treated with staples and an interval development of a right frontoparietal convexity subdural hematoma.  
• The facility failed to ensure the safety of a resident during an assisted transfer, which resulted in the resident falling backwards and developing a subdural hematoma and laceration to the back of the resident head for 1 of 3 residents reviewed for falls. 
• The facility failed to ensure two of three residents reviewed for falls were provided safe transfer assistance. This deficient practice resulted in significant injuries for both residents which required transfers to acute care centers for treatment.  
• The facility to ensure person-centered fall interventions were in place for a resident, (Resident B) who had a history of falls, which resulted in actual harm when he fell out of bed and sustained multiple rib fractures and hospitalization. The facility failed to ensure a resident, (Resident C) who had a history of falls, also received person-centered interventions as outlined in her plan of care for 2 of 3 residents reviewed for falls.  

 F684 – Quality of Care  

• The facility failed to ensure a resident that was identified with an alteration in skin integrity had an assessment conducted upon identification of the skin impairment, upon readmission to the facility, and weekly thereafter. The facility also failed to implement a treatment timely and continued treatment to a skin alteration that was later identified with osteomyelitis that required hospitalization, intravenous antibiotic therapy, and surgical intervention for 1 of 1 resident reviewed for skin impairment.  
• The facility failed to provide routine suprapubic catheter care and to provide routine nephrostomy tube care to a resident, resulting in a hospitalization for sepsis, acute kidney injury, and UTI associated with his nephrostomy catheter for 1 of 3 residents reviewed for urinary catheter care.  
• The facility failed to ensure a resident who received a left foot/toe injury had thorough and accurate assessments of the area and failed to treat the area as ordered by the physician, which resulted in the resident being admitted into the hospital with diagnosis of left great toe infection, cellulitis of the left foot, and a MRI of the foot that indicated a result of suspicious for osteomyelitis of the left great toe for 1 of 2 residents reviewed for injuries.  

  F600 – Free from Abuse and Neglect  

• The facility failed to ensure a resident was free from mental and verbal abuse and intimidation, failed to ensure a staff member intervened while a resident was being mentally and verbally abused and intimidated, and failed to provide 72-hour psychosocial follow-up for 1 of 3 residents reviewed for abuse. (Resident B) indicated while being abused by the Executive Director, she thought she was going to be hit, her personal space was invaded, she was in fear for her life, and following the incident she thought the Executive Director sent an unidentified man “hit man” into the facility to harm her in retaliation for the ED being suspended.  

 F686 – Treatment/Services to Prevent/Heal Pressure Ulcer  

• The facility failed to prevent a pressure ulcer from developing on the heel and buttock, for 1 of 3 residents reviewed for pressure ulcers.  

 F760 – Residents are Free of Significant Med Errors  

• The facility failed to ensure a resident received the correct medication for 1 of 1 resident reviewed for significant medication error. (Resident 20) required an intensive care stay in the hospital for 5 days.  

 F622 – Transfer and Discharge Requirements  

• The facility failed to ensure a resident was free from involuntary transfers without identified necessity for 1 of 1 resident reviewed for involuntary transfers (Resident C). This deficient practice resulted in emotional distress to the resident requiring an extra dose of psychoactive medication, the resident experiencing a stressful life change, the resident being moved to a facility not of the family’s choosing, and the resident now residing in a facility at greater distance for the family to drive.  

 IJ/SSQC citation as follows:  

F600 – Free from Abuse and Neglect  

• The facility failed to ensure resident to resident abuse did not occur related to sexual abuse resulting in a severely cognitive resident and a cognitive resident found in an unsupervised sexual situation for 2 of 5 residents reviewed for abuse.  

The immediate jeopardy began on 8/24/23, when the facility failed to prevent resident to resident sexual abuse when a cognitively alert male resident was found with a severely cognitively impaired female resident in an inappropriate sexual position. The IJ was removed on 9/27/23, (day survey was completed) but remained at a lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.  

Contact Ldavenport@ihca.org if you have any questions or would like further information.