The Indiana Department of Health conducted forty-five recertification surveys in September, and of those, two were deficiency free.
Top ten tags in Indiana as of October 2024 – QCOR
| Complaint Surveys | Standard Surveys |
| F689 Free of Accident Hazards/Sup/Devices | F761 Label/Store Drugs Biologicals |
| F684 Quality of Care | F684 Quality of Care |
| F609 Reporting Alleged Violations | F880 Infection Prevention and Control |
| F677 ADL Care Provided to Dependent Res | F812 Food Procurement/Store/Serve/Sanit |
| F880 Infection Prevention and Control | F695 Respiratory/Tracheostomy/Care and Suct |
| F600 Free from Abuse and Neglect | F677 ADL Care Provided Dependent Residents |
| F580 Notification of Changes | F689 Free of Accident Hazards/Sup/Devices |
| F686 Treatment Services to Prevent Heal PUs | F656 Development Implementation CCP |
| F755 Pharmacy Services Provided/Reports | F657 Care Plan Timing and Revision |
| F550 Resident Rights/Exercise of Rights | F690 Bowel and Bladder Incontinent, Catheter, UTI |
There was a total of four G-Level citations as follows:
F686 (three times) – Treatment and Services to Prevent/Heal Pressure Ulcers
- Failed to ensure staff effectively identified skin impairment on the left inner calf from friction and shear was correctly identified as a pressure injury, failed to ensure a physician’s order was received prior to the use of a medical device, and failed to ensure a resident with a history of pressure injuries received effective treatment and services to prevent the wound from deteriorating, from developing infection, or to prevent the development of a second wound for 1 of 1 residents reviewed for wound care. This deficient practice resulted in Wound 1 deteriorating to a stage three pressure injury with infection and required sharp debridement.
- Failed to ensure a resident was provided the care and services to prevent the development of skin breakdown for four areas, to ensure the skin assessments identified a pressure ulcer prior to it becoming a Stage 3 wound, and the worsening of the Stage 3 pressure ulcer. This resulted in the wound worsening to a Stage 4 pressure ulcer.
- Failed to ensure services were effectively provided to identify, monitor, and treat an area of facility-acquired skin impairment and failed to ensure interventions were implemented to provide effective pressure relief to the wound for a resident admitted without skin impairment for 1 of 4 residents reviewed for pressure injuries. This resulted in the facility-acquired skin impairment deteriorating to a Stage 3 pressure injury with infection that required antibiotic therapy.
F689 (1 time) – Free of Accident Hazards/Supervision/Devices
- Failed to ensure staff transferred a dependent resident with a mechanical lift in accordance with physician orders and the plan of care for 1 of 3 residents reviewed for mechanical lifts. This practice resulted in a fall and the resident then sustained a left shin fracture.
There were two SSQC/Immediate Jeopardy citations as follows:
F600 – SSQC/ IJ (1 time) – Free from Abuse and Neglect
- Failed to protect the residents’ right to be free from sexual abuse by a resident residing on the same locked unit for 2 of 3 residents reviewed for abuse resulting in Immediate Jeopardy when the facility failed to keep the residents separated and prevent further abuse.
The immediate jeopardy began on 9/22 when a cognitive impaired resident (Resident B) was observed by staff touching another cognitively impaired resident (Resident C) in the genital region in the shared area after breakfast. Later that same day, Resident B and Resident C were found together in bed with Resident B’s hand was on Resident Cs bare stomach and legs intertwined. In the afternoon, Resident B and Resident C were observed in another resident’s room with Resident’s pants down without a brief and his back turned towards the door and his hands on Resident C’s shoulders.
F689 SSQC/IJ (1 time) – Free of Accident Hazards/Supervision/Devices
- Failed to ensure adequate supervision and a secure environment was in place to prevent a resident with dementia from exiting the facility and leaving the property. On 9/3, after being last seen by staff around 2:20 P.M., a resident exited the facility and was not realized to be missing until 3:15 P.M. when a search for the resident began. The Activity Director located the resident approximately two hundred yards off the facility property along a gravel road.
The Immediate Jeopardy began on 9/3 when the facility failed to ensure Resident C did not exit the facility through an unsecured door toward the back of the building, located near the facility kitchen, and either walked behind or wheeled herself off the property and approximately 200 yards (about 182.88 m) along a gravel road. The Activity Director located Resident in a wheelchair alongside the gravel road while searching in her vehicle. The resident was returned to the facility without incident or injury.