August Skilled Nursing Facility Citation Update – G Level/SSQC & IJ’s

The Indiana Department of Health conducted fifty (50) recertification surveys and of those four (4) were deficiency free. There were eleven G Level citations and four Immediate Jeopardy citations, three being SSQC.

G Level Citation are as follows:

Tage 600 (3 times) – Free from Abuse and neglect

• Based on record review and interview, the facility failed to implement effective interventions to prevent physical and verbal Resident to Resident abuse from recurring. This deficient practice resulted in Resident B exhibiting physically abusive behaviors which caused harm to 3 of 3 residents reviewed from abuse.
  • Resident B had a history of physical behavior (pushing, touching others without permission, and making contact leaving evidence of that contact). No new interventions were put into place after each event.  
• Based on observation, record review and intervention, the facility failed to ensure a cognitively impaired resident who wandered (Resident D) was free from resident-to-resident physical abuse perpetrated by a resident known to be physically abusive towards others when approached (Resident C) for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident D sustaining a head laceration and required emergent treatment at the hospital with six sutures to repair.
  • A local police department’s case report indicated the officer got to the door of Resident’s C’s room; blood was observed on the floor inside the entryway. Resident C was asked about what happened and advised that Resident D walked into his room while asleep. Resident C was unsure how many times he stomped on Resident D’s head. Resident C also stated that he had thoughts of harming others. An employee had indicated to the officer that they had not seen the incident but witnessed Resident C standing over the top of Resident D while yelling.
• Based on interview, observation, and record review, the facility failed to prevent three events of resident-to-resident physical abuse perpetrated by Resident B for 3 of 5 residents reviewed for abuse. This deficient practice resulted in Resident D, Resident G, and Resident E being physically assaulted by Resident B and experiencing negative psychosocial outcomes.

Resident B perpetrated resident-to-resident physical abuse on three events as follows:

Event 1: 7/8/2024 indicated an event of resident-to-resident physical abuse perpetrated by Resident B occurred at 5:10 p.m. when Resident B was sitting in a wheelchair on the threshold of a staff member’s door. The report indicated Resident D attempted to pass through the threshold, Resident B would not move, and Resident B “tapped” Resident D on the shoulder. Interventions for Resident B and Resident D were listed as: head-to-assessments, 15-minute checks, psychosocial follow up, reviewing of care plans, and updating care plans as needed.

Event 2: 8/6/2024 indicated an event of resident-to-resident physical abuse occurred at 5:09 p.m., when Resident G attempted to get coffee in the dining room where Resident B was sitting in a wheelchair. Resident G asked Resident B to move multiple times then nudged Resident B’s wheelchair. Resident B became agitated and “made contact with” Resident G’s forearm with an “open hand.” Interventions were listed as: immediately separating Resident B and Resident G, Resident B was placed on “line of site for remainder”, Resident G was placed on15-minute checks, and care plans for Resident B and Resident G were reviewed and updated as needed.

Event 3: 8/10/2024 indicated an event of resident-to-resident physical abuse perpetrated by Resident B occurred at 8/5/2024 at 1:30 a.m. Resident E indicated Resident B “made contact” with the right side of Resident E’s head. Interventions were listed as: psychosocial support for Resident B and Resident E, Resident B was placed on 15-minute checks, and care plans for Resident B and Resident E reviewed and updated as needed. The follow up on the incident, dated 8/15/2024, indicated Resident B was transferred to a neuropsychological hospital for evaluation.

Tag 690 (2 times) – Bowel/Bladder Incontinence, Catheter, UtI

• Based on interview and record review, the facility failed to ensure services were provided to a resident with an indwelling urinary catheter to prevent the development of infection for 1 of 1 resident reviewed for a catheter-associated urinary tract infection (CAUTI). This deficient practice resulted in Resident 32 developing a CAUTI with septic shock and pneumonia. Resident thirty-two required artificial ventilation and treatment at a hospital-based intensive care unit.
• Based on interview and record review, the facility failed to ensure lab specimens were obtained immediately with symptoms of urinary tract infection and laboratory results were reviewed in a timely manner for a resident with an indwelling urinary catheter to prevent urinary tract infection for 1 of 3 residents reviewed for quality of care (Resident F). This deficient practice resulted in a delay of treatment and the resident developed urosepsis with acute kidney failure with a systemic inflammatory response syndrome (SIRS) and died.

Tag 760 (2 times) – Residents are Free of Significant Medication Errors

• Based on interview and record review, the facility failed to ensure a resident without diabetes was free from a significant medication error for 1 of 1 resident reviewed for significant medication errors (Resident L). This deficient practice resulted in Resident L receiving an overdose of rapid-acting and long-acting insulins and a significant change in condition that required emergent, intensive care at an acute hospital for treatment of low blood sugar. The resident was mistaken for another resident.
• Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medication errors. Medications used to prevent and treat seizures were not administered. This deficient practice resulted in Resident M requiring an emergency room visit after experiencing three seizures in thirty minutes.  

Tag 689 (1 time) – Free of Accident Hazards/Supervision/Devices

• Based on interview and record review, the facility failed to ensure interventions to prevent falls were effectively implemented when Resident C exhibited signs and symptoms of lethargy, drowsiness, and sedation and failed to ensure staff used a gait belt during the transfer of Resident D who required more than limited assistance with transfers for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident C falling in the shower and sustaining fractures to the left shoulder blade, the left rib, and the endplate of the third lumbar spinal disc.

Tag 697 (1 time) – Pain Management

• Based on observation, interview and record review, the facility failed to administer medication as needed prior to a dressing change. This deficient practice resulted in severe pain during a treatment for 1 of 1 resident observed for wound care.

Tag 684 (1 time) – Quality of Care

• Based on interview and record review, the facility failed to ensure staff thoroughly and completely assessed a resident after a fall with head injury, failed to ensure the fall was effectively documented with specific fall details to ensure interventions were immediately implemented to prevent further falls, failed to effectively monitor the neurological status of the resident safter a subdural hematoma was identified for 1 of 3 residents reviewed for falls. (Resident D) This deficient practice resulted in the resident experiencing right-sided shaking. Slurred speech altered mental status, and an active brain bleed that required a craniotomy to repair.

Tag 686 (1 time) – Treatment/Services to Prevent/Heal Pressure Ulcer

• Based on observation, interview, and record review, the facility failed to prevent the development and worsening of facility acquired pressure ulcers for 2 of 6 resident reviewed for pressure ulcers. This deficient practice resulted in worsening and infection of an unstageable pressure ulcer and development of a Stage III pressure ulcer.

IJ/SSQC citations are as follows:

F689 (2 times) – Free of Accident Hazards/Supervision/Devices

• Based on interview, record review, and observation, the facility failed to ensure a shower bed was comprehensively inspected for safety or function by the maintenance staff or by the CAN prior to its use, failed to ensure a resident was repositioned on a shower bed using two staff in accordance with the plan of care, and failed to ensure the resident was rolled toward the CAN providing care in accordance with the CAN training record for 1 of 3 residents reviewed for accidents (Resident B) This deficient practice resulted in Resident B falling from a shower bed and sustaining a subdural hematoma with midline shift (a potentially fatal traumatic brain injury), a fracture of the left humerus (the largest one of the upper extremity), and a facial laceration.The immediate jeopardy began on 8/5/24, when the facility failed to ensure a resident’s safety during a shower when a CNA did not follow proper procedure guidelines while turning a resident in a shower bed. The facility did not assess the shower beds for safety per the manufacturer’s instructions and the Maintenance Director altered the shower bed by replacing pipes and putting the device back into service after the fall. The fall report indicated Resident B was in the shower room. It was reported by CNA 2 that during the resident’s shower the side rail to the shower bed gave out and the resident fell. The resident was awake and talking to the nurse. She verbalized some understanding of the incident. She was noted to have a one-inch laceration with a hematoma (bruise) present above the right eye. There was a mechanical failure with the shower bed rail. The resident was sent to the hospital. A Trauma assessment, dated 8/5/24, indicated the resident’s injuries by exam and radiographic findings/plan indicated the resident had a TBI (Traumatic Brain Injury) with midline shift, neurosurgeon consulted and non-operation with poor prognosis, and a left humerus fracture with no intervention and given comfort care. The resident died at the hospital on 8/8/24.

• Based on interview and record review, the facility failed to ensure supervision of two cognitively impaired residents; and failed to follow the facility elopement policy resulting in elopements for 2 of 2 residents reviewed for accidents. Resident B exited the facility by a side door and walked 0.5 miles to a gas station. An hour later, the residents’ brother notified the facility that Resident B had left the facility. Resident C exited the facility by the front door after being returned to the facility by the son after an overnight stay. Twenty minutes later the resident was found outside the facility walking in the grass away from the facility next to the road, Highway 62 (Resident B and Resident C). This deficient practice resulted in an Immediate Jeopardy. This Immediate Jeopardy began when the facility failed to ensure a cognitively impaired resident was adequately supervised and allowed to leave by the front door. On another day another cognitively impaired resident left the facility by the side door. The second resident had a history of wandering and was not adequately monitored for these behaviors. Additionally, the facility failed to develop and implement interventions to reduce the risk of falls, fall risk assessments were not completed after falls, neurological checks were not completed after unwitnessed falls for 2 of 7 residents.

F698 (1 time) – Dialysis

• Based on interview and record review, the facility failed to ensure residents who required dialysis services continued to receive those services in accordance with physician orders when the facility-based dialysis center closed on 8/12/2024 for 6 of 7 residents reviewed for dialysis services. (Resident D, E, F, R, S and V). Residents did not receive dialysis services as ordered by their physician and had to seek medical treatment and emergency dialysis from the hospital. During an interview, on 8/22/24 at 1:54 P.M., the facility NP indicated the in-house dialysis center had not given the facility much notice, two-four weeks prior to their closure. She indicated she had rounded on all the dialysis residents due to problems with the facility setting up dialysis for those residents requiring dialysis and would be missing their Monday dialysis. She had instructed Nurse Manager 12 to send residents to a local ER if they had not had dialysis by Wednesday the 14th. She indicated she was contacted about Resident F having some concerns which may or may not have been related to him not having dialysis on his regular scheduled Monday and had ordered the nurses to send him to the ER on 8/12/2024. There was no documentation provided the NP had notified her supervising MD of the issues regarding missed and/or unscheduled dialysis treatments per orders.

F622 (1 time) – Transfer and Discharge Requirements

• Based on record review and interview, the facility failed to honor a resident’s right to return to the facility from an emergency room visit following a resident -to-resident altercation (Resident C). The facility failed to demonstrate inability to meet the resident’s needs or that the resident was an immediate danger to others with interventions attempted. The Immediate Jeopardy began on 8/16/24 when the facility discharged the resident with his belongings to a hotel located twenty-six miles away from the facility. with a two-day paid stay. This puts the resident at risk of harm related to lack of a safe environment, placing the resident at risk of serious accidents. The Immediate Jeopardy was removed when the facility provided education to managers and nurses regarding transfer and discharge rights of a resident, but noncompliance remained at the lower scope and severity of harm that is not Immediate Jeopardy because the resident was found on a sidewalk by police back in the same city the facility is located in and was hospitalized for dehydration and acute kidney injury.

F626 (1 time) – Permitting Residents to Return to the Facility

• Based on record review and interview, the facility failed to ensure facility policies were implemented to allow a resident to return to the facility for care following an emergency room visit. The resident was not given enough notice to appeal the discharge before being transported to and left at a hotel twenty-six miles away from the facility. The Immediate Jeopardy began on 8/16/24, when the facility failed to allow a resident to return to the facility after a hospital visit per facility policy. The Immediate Jeopardy was removed when the facility completed education of management, and nurses regarding discharge rights and the facility policy for resident discharge on 8/22/24.