ISDH IJ/SSQC Update

There were 2 events in the month of October that led to 1 citation that was SSQC only and 2 citations that were IJ and SSQC.  Reaching back to a frequent issue in 2012, unsafe hot water temperatures were found in a facility and resulted in F323 being cited (SSQC only).  The facility was aware of the water temperature issue due to a faulty water heater, that was replaced, and a newly-installed mixing valve.  However, these remedies did not solve the hot water problem and several residents were aware of it and had reported it to staff.  The Administrator knew the maintenance director was checking the water temperatures, but was not aware that a log was not being maintained to check for patterns.  Temperatures exceeded the 120-degree limit, and at some faucets water more than 150, 160 and 180-degrees Fahrenheit.

The other October event concerned an allegation of abuse and the failure to ensure timely reporting of the allegation to the Administrator and the ISDH. This event led to two citations, F225 and F226, at the IJ and SSQC levels.  There was an allegation that a CNA had tied a resident’s gown to the resident’s wheelchair on 10/1/13, but the incident was not reported to the DON until 10/2/13 and it also did not reach the Administrator until 10/4/13.  The accused CNA was seen manipulating the resident’s gown on surveillance tape, and continued to work until the Administrator received the report.  A second CNA appeared to be aware of the alleged abuse, did not report it, and also was still working until the Administrator received the report.    The ISDH was notified via incident report the same day the Administrator was made aware of the issue, but this was 3 days after the alleged abuse was known to staff.

Click here to view a summary of 2013 IJ/SSQC citations and for the citations from October.