SNF Immediate Jeopardy, Substandard Standard of Care, and G Level Citation Update

The Indiana Department of Health conducted Forty-one (41) Recertification surveys and of those five (5) or 12 % were deficiency free.

There was a total of 2 SSQC citations and 3 Immediate Jeopardy citations as follows:

• F880 (IJ (Immediate Jeopardy)) – Infection Prevention & Control – Failure to provide nursing services in a safe and sanitary manner to prevent the transmission of communicable disease and infections related to not sanitizing the glucometer between uses for 2 of 16 residents randomly observed for glucose monitoring. The facility identified two of the five residents with bloodborne communicable disease who were residents in the facility that used the shared glucometer. The deficient practice resulted in a high potential risk for disease transmission for the sixteen residents in the facility who required glucometer blood sugar testing. The facility also failed to ensure services were effectively provided to prevent the development of infection for 1 of 1 resident reviewed for indwelling urinary catheter care, 1 of 1 resident randomly observed for accessing an ice chest, 3 of 3 residents randomly observed for nursing care by 2 of 3 nursing staff, and 1 of 1 resident reviewed for respiratory care.

The Immediate Jeopardy began on 5/13/24 when the facility staff was observed attempting to complete glucose blood testing on a resident after prior resident testing without the shared glucometer being sanitized. There were two residents requiring blood glucose testing in the facility who were identified as having bloodborne disease.

• F689 (IJ/SSQC) – Free of Accident Hazards/Supervision/Devices – Failure to ensure adequate supervision and secured environment was in place to prevent a resident with dementia from exiting the facility and leaving the property. On 4/10 24, after being last seen by facility staff around 8:00 P.M>, a resident exited the facility and was not realized to be missing until 8:45 P.M. when the resident was noticed to not be in her room. The resident was located by local law enforcement at 9:11 P.M. approximately 2.4 miles away at a residential residence along US Highway 50.

The Immediate Jeopardy began on 4/10/24 when the facility failed to ensure Resident C did not exit the facility through a window in the front of the building, located in the dining room, and walked approximately 2.4 miles to a residential residence. Local law enforcement located the resident. The resident was treated at a local hospital for a facial laceration and minor head injury from multiple falls in a ditch before returning to the facility. The immediate jeopardy was removed on 5/2/24. Noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

• F689 (IJ/SSQC) — Free of Accident Hazards/Supervision/Devices — Failure to ensure adequate supervision was proved to prevent a cognitively impaired resident on the memory care unit with a history of food stuffing from ingesting and aspirating a large amount of unchewed food.

The Immediate Jeopardy began on 4/16/24 when a cognitively impaired resident on the memory care unit with a history of stuffing food into her mouth and swallowing without chewing was found unresponsive with sausage in her mouth and airway after evening meal. The resident had an order for a diet with ground meat for meals. There were not dietary cards nor round meat provided for the evening meal on 4/16/24. The staff working provided the resident with polish sausage cut into pieces. The resident was found unresponsive after the evening meal with a large amount of unchewed sausage in her mouth and airway. The Heimlich Remover and CPR were completed resulting in more sausage being found in the resident’s mouth. The resident was not able to be revived, even after EMS (Emergency Medical Services) arrived and took over care and was pronounced deceased by EMS (Emergency Medical Services). Cause of death by Coroner was aspiration of food.

• F805 (IJ – SS-K) — Food in Form to Meet Individual Needs –Failure to ensure ground meat was provided in accordance with the physician orders and failed to ensure specialized dietary instructions were provided to nursing staff for 6 of 6 residents on a memory care unit reviewed for a mechanically altered with ground meat diet. The deficient practice resulted in a cognitively impaired resident with a history of food stuffing, ingesting the regulator meat, the resident’s airway becoming blocked, and the resident expired.

The Immediate Jeopardy began on 4/16/24 when a cognitively impaired resident on the memory care unit with a history of stuffing food into her mouth and swallowing without chewing was found unresponsive with sausage in her mouth and airway after evening meal. The resident had an order for a diet with ground meat for meals. There were not dietary cards nor round meat provided for the evening meal on 4/16/24. The staff working provided the resident with polish sausage cut into pieces. The resident was found unresponsive after the evening meal with a large amount of unchewed sausage in her mouth and airway. The Heimlich Remover and CPR were completed resulting in more sausage being found in the resident’s mouth. The resident was not able to be revived, even after EMS (Emergency Medical Services) arrived and took over care and was pronounced deceased by EMS (Emergency Medical Services). Cause of death by Coroner was aspiration of food.

There was a total of seven (7) G level citations in May and they are as follows:

• F689 (3 times) Free of Accident Hazards/Supervision/Devices

Failure to implement interventions to eliminate and/or reduce a resident’s risk of being burned by therapy modality by not ensuring the maintenance/inspection of a hydrocollator (a temperature-controlled water bath for placing heating pads) was up to date, not maintaining a current temperature log for the hydrocollator, not testing the temperature of the hydrocollator prior to use on a resident, and not following the policy/or procedure for use of a hydrocollator and heat pads resulting in a resident receiving a blistering burn on his hand for 1 of 3 residents reviewed for wounds.

Failure to ensure a resident received adequate supervision while performing an activity of daily living. This failure resulted in the resident experiencing an avoidable, unwitnessed fall which caused pain at a rating of nine out of ten, and a concussion for 1 of 5 residents reviewed for staffing.

Failure to ensure adequate supervision was provided to Resident C, an aggressive resident, to protect Resident B, a cognitively impaired resident from being pushed to the floor for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident B falling and requiring hospitalization for surgical repair of a right femur fracture.

• F740 – Behavioral Health Services – Failure to ensure a resident’s plan of care for behavioral health was implemented and evaluated after having physical behavioral symptoms directed towards staff and other residents, document a resident’s behaviors in the clinical record, document interventions in response to such behaviors, document the reasoning for administration of an intramuscular injection of antianxiety and antipsychotic medications, and ensure other residents’ safety was maintained during behavioral episodes to where a resident was found to have their hands around another resident neck that resulted in redness. Residents felt fearful, anxious, and the need to relocate to another nursing facility.
• F690 Bowel/Bladder Incontinence, Catheter UTI (Urinary Tract Infection) – Failure to ensure urinary catheter outputs were monitored and documented for 3 of 3 residents reviewed for urinary catheters, resulting in Resident D being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter. The care plan and policy of the facility was not followed.
• F760 Residents are Free of Significant Med Errors – Failure to ensure a resident was provided his seizure medications as ordered for 1 of 3 residents reviewed for discharges. This resulted in a resident having a seizure and having to be hospitalized.

Forward questions to ldavenport@ihca.org.