SNF Citation Update – G Level, SSQC, and Immediate Jeopardy

The Indiana Department of Health conducted Forty-two (42) recertification surveys for the month of March 2024 with zero deficiency free surveys. There was a total of seven providers with a G Level citation and three providers with SSQC/IJ citation. 

The G Level citations are as follows: 

Tag 690 (1 time) – Bowel/Bladder Incontinence, Catheter, UTI  

• The facility failed to ensure effective treatment and services were provided to residents with Urinary Tract Infections (UTI’s) in 2 of 3 residents reviewed for UTI’s. Urinalysis (UA) and Culture and Sensitivity C&S) tests were not completed or followed up on, antibiotics were not prescribed in a timely manner, and catheter care was not performed correctly. This deficient practice resulted in Resident 21 being hospitalized for the treatment of pyelonephritis (a kidney infection).  

Tag 686 (2 times) – Treatment/Services to Prevent/Heal Pressure Ulcer  

• The facility failed to ensure services to prevent the development of pressure injuries were effectively provided to Resident D, who was admitted to the facility without a pressure ulcer and developed a facility-acquired unstageable pressure ulcer and also failed to ensure services were provided to Resident E, who developed a facility-acquired stage three pressure ulcer, in accordance with the physician orders, for 2 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in Resident D developing a facility-acquired wound initially identified by the facility as an unstageable pressure injury on the sacrum that required surgical debridement after re-admission into the hospital.  
• The facility failed to ensure a resident admitted to the facility without pressure-related skin impairment did not develop a pressure injury for 1 of 2 residents reviewed for pressure injuries. This deficient practice resulted in Resident 5 developing a facility that acquired Stage 3 pressure ulcer on the left buttock.  

Tag 684 (2 times) – Quality of Care  

• The facility failed to ensure services were provided to effectively administer back blows for a choking resident in accordance with treatment guidelines established by the facility and failed to ensure the plan of care was effectively revised with accurate care information. This deficient practice resulted in a resident experiencing a choking episode with a change in the level of consciousness which required emergent treatment. The facility also failed to ensure residents maintained upright positioning while sitting in chairs, to ensure the physician was notified for blood sugars above specified parameters and to ensure weights were completed daily for 4 of 4 residents reviewed for quality of care.  During observation, a resident was sitting up in wheelchair in a shared area. The head of the resident was tilted to the right with chin tilted towards chest. There was no positioning cushion in the wheelchair. A physician order indicated the resident was to always have a right lateral support in her chair to ensure an upright sitting position. Staff interviewed did not know the type of support the resident was supposed to have in her wheelchair.  

• The facility failed to identify and appropriately manage an acute change in condition, delaying hospital evaluation by 18 days, related to worsening respiratory symptoms, irregular blood sugar levels, and abnormal laboratory results not addressed. This deficient practice resulted in extended hospitalization for acute kidney injury on top of chronic kidney disease and cardia issues. The facility failed to identify and address bowel habits, resulting in hospitalization with acute constipation, failed to notify the physician of blood sugars beyond the ordered parameters, and failed to assess skin abnormalities for a resident on anticoagulant medication related to bruising and scabbing for 2 of 3 residents reviewed for hospitalization, 1 of 3 resident reviewed for insulin use, and 2 of 3 residents reviewed for skin conditions, non-pressure related.  

Tag 600 (2 times) – Free from Abuse and Neglect  

• The facility failed to protect a resident’s right to be free from verbal abuse from another resident, which resulted in emotional distress, and physical abuse by a staff member, for 3 of 4 residents reviewed for abuse.  
• The facility failed to ensure Resident C, a resident with dementia, was free from resident-to-resident sexual abuse by Resident B, for 2 of 2 residents reviewed for sexual abuse. Using the reasonable person concept, it is likely this would lead to fear, confusion, and anxiety for Resident C. 

SSQC/IJ Citations are as follows:  

Tag 689 (2 times) – Free of Accident Hazards/Supervision/Devices  

• The facility failed to provide adequate supervision to prevent a resident with a history of elopement from walking out the same emergency exit door on three consecutive days for 1 of 3 residents reviewed for elopement. Resident B was found 1.1 miles away in an empty commercial lot by the police. The Immediate Jeopardy began on March 23, 2024, when Resident B exited the facility without supervision. The Immediate Jeopardy was removed, on 3.28.24 at 4:45 p.m. but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. During an interview on 3/26/24 with CNA 1 that knew that Resident B had left the facility on 3/23/24 on evening shift. Resident B left the facility again on 3/25 on evening shift. Resident B was not on 1-to-1 supervision when CNA arrived at the facility on 3/25/24, nor was Resident B on 1-to-1 supervision during night shift. On 3/26 the emergency door in the dining room was observed. The emergency exit door was shut and had a keypad to the right of the door. The small battery operated; door alarm was not observed on the door nor the door frame. The door leads out to a front porch that was not secured. The porch was approximately fifteen feet from a busy main street. There were cars parked on each side of the street which caused port visibility to see oncoming traffic.  During an interview on 3/26 with staff … indicated on 3/23/24 at an unknown time, Resident B walked out the emergency exit door in the dining room, at the front of the facility. The alarms did not sound because that door was not connected to the internal alarm system, but did have a small battery operated, generic alarm that would sound like a doorbell if the door opened. The staff received a call from the police on 3/23/24 and asked if Resident B was a resident at the facility. Resident B returned to the facility accompanied by the police. Resident B walked out the same emergency exit door on 3/24/24 and again on 3/25/24. Resident B eloped in July 2023 as well.  

• The facility failed to provide effective supervision to prevent a cognitively impaired resident from exiting the second story locked memory care unit through an open window located approximately 13 feet above the ground by using a gait belt and failed to conduct an elopement assessment when the cognitively impaired resident verbalized the intention to elope from the facility for 1 of 3 residents reviewed for accidents. Resident B sustained a fractured left heel, a fractured left ankle, two fractures of the sacral vertebras, and a thoracic vertebra fracture. The Immediate Jeopardy began on 3/16/24 when a cognitively impaired resident with diagnosis of Alzheimer’s who was admitted one day before to the locked memory care unit, was observed with exit seeking behaviors throughout the day on 3/16/24. Resident observed to attempt to leave the unit, opening a window on the second story porch, taking her belongings to the porch, and asking to leave out the window. The gait belt was tied to a chair next to the window and Resident B was missing. Resident B was found outside crawling in the parking lot and holding a pillow with blood on it.  

Tag 744 (1 time) – Treatment/Service for Dementia  

• The facility failed to provide individualized dementia care and supervision of a newly admitted resident with Alzheimer’s dementia for 1 of 3 residents reviewed for dementia care which resulted in the resident exiting the locked memory care unit through a second story window approximately 13 feet about the ground and fracturing her left heel, left ankle, two sacral vertebrae, and thoracic vertebra.  
•  The immediate jeopardy began on 3/15/24 when a cognitively impaired resident with a diagnosis of Alzheimer’s dementia was admitted to the nonsmoking locked memory care unit. Resident B was admitted from an assisted living facility, required minimal assistance with ADLs (Activities of Daily Living), and required no supervision when smoking cigarettes. Resident B was observed by facility staff to exhibit exit seeking behaviors throughout the day on 3/15/24 and 3/16/24. Resident B was observed to attempt to leave the unit, attempting to follow residents’ family off the unit, and asking to leave the facility. Resident B refused her nicotine patch on 3/16/24 and indicated it did not work for her. On 3/16/24 at 8:30 p.m. staff observed a window on the unit’s second story sunroom, that was 13 feet above ground level, was open and staff observed a 2 (two) foot gait belt was attached to a chair located in the interior of the facility and hanging out the window on the exterior of the building, the window and Resident B was missing. Resident B was found outside the facility below the open window in the parking lot. She was taken to the hospital and diagnosed with a fracture of the left calcaneal (heel), a fracture of the left malleolus (ankle), a fracture of two sacral vertebrae (S2 and S3), and a burst fracture of the thoracic spine vertebra at T12. The Administrator (ADM) was notified of the immediate jeopardy at 5:01 p.m. on 3/20/24. The immediate jeopardy was removed on 3/21/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. 

F690 (1 time) – Bowel/Bladder Incontinence, Catheter, UTI  

• The facility failed to assess and treat a resident’s urinary catheter and follow-up on continued hematuria resulting in immediate jeopardy when the resident with a history of UTI and septic shock did not have a follow-up with a Urologist for continued hematuria and blood clots, had a change in condition with his urinary catheter, and was sent to the hospital several hours later in septic shock and respiratory failure.  The Immediate Jeopardy began on 2/27/24 when Resident B, with a history of urinary catheter, severe sepsis with septic shock, and urinary tract infection on 11/13/23, had a distended abdomen and low urine output in the foley drain bag on 2/27/24. The catheter was changed, and bloody urine was returned. The physician was not notified, and no assessment or vital signs were obtained. On 2/28/24 Resident B had black emesis, blood clots from the catheter, and bloody urine. Vital signs were B/P 68/49, pulse 107, and temperature of 96.9. The resident was transferred to the hospital and diagnosed with septic shock, respiratory failure, UTI, bladder hemorrhage with probale cyctitis, pneumonia and anemia. Resident was intubated. Resident expired on 3/1/24.  The Immediate Jeopardy was removed on 3/7/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.