IJ/SSQC Update – August and September 2013

Due to delays in obtaining IJ/SSQC data from August, no update was provided last month.  However, data has been obtained for August and September and can now report to catch up on the year to date.  Through July of 2013, there had been 7 events leading to IJ tags, and 8 events leading to SSQC tags.  August and September, combined, saw 5 events leading to IJ tags and 6 events leading to SSQC tags.  There were a couple of IJ/SSQC citations issued that had not risen to that level in more than 3 years (F311, F333, F520).  Click here for the August and September surveys, as well as the year to date summary.

• August Summary

In August a facility was cited for alleged failure to timely report allegations of abuse to the administrator and to timely investigate said allegations.  The first issue appeared to stem from alleged rough care/physical abuse that was verbally reported to her by an Activity Aide, but that SSD did not report it to either the DON or Administrator and admitted that she had forgotten to do so.  The SSD was approached about the alleged verbal abuse when the QA Consultant approached her about it after having received an allegation of abuse report.  A second issue for this facility related to an incomplete and inconsistently documented abuse allegation investigation.  Both F225 and F226 were cited.

Also in August, F309 was cited for a facility’s alleged failure to ensure availability of CPR certified staff on each shift for residents with full code status, and for residents that wish to have full resuscitation in the event of cardiopulmonary arrest.  Based on the survey document, the facility has residents that were documented as full code for all hours of the day, however the facility also documented that did not have CPR certified staff 24 hours per day.  The DON herself had let her CPR certification lapse and only 4 of 10 licensed staff were CPR certified at that time.  A separate facility was cited for a violation of F329 related to PT/INR monitoring and PICC line complications.  The issue here appeared to be related to confusion on when the PT/INRs were supposed to be conducted.

The last issue in August resulted in F333 and F520 being cited at the IJ level for first time in more than 3 years.  According to the survey documentation, a resident was administered his roommates medications after the resident was not identified correctly by the LPN who administered the medications (F333 was cited).  A citation as also issued for the alleged failure of the QA committee to implement plans of action for a number of concerns identified by the committee, nor was there evidence of a system being in place to monitor implementation of plans to address issues identified by the QA committee (F520 was cited).

• September Summary

A facility was cited for alleged violation of F225 and F226 for issues related to timely reporting of abuse allegations and failures to perform criminal history checks on employees.  The reporting of abuse citation stemmed from an incomplete abuse investigation and failure to report the incident to the ISDH.  In addition, a second issue was noted concerning another incomplete abuse investigation.  Regarding criminal history checks, the surveyor noted that there were seven then-current employees for whom a completed criminal history check could not be found or produced by facility staff.  It appeared there was a gap as to who was assigned responsibility for performing criminal history checks due to the absence of a business office managed that used to perform them, but was no longer employed.  This facility was also cited F311 for alleged failure to ensure a resident received restorative services to prevent loss of ability to ambulate.  It appeared that the facility’s therapy company had discontinued services at the facility due to a dispute with the facility, and adequate therapy staffing had not been found to provide services thereafter.

Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk.  It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement.  Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.