March 2014 IJ/SSQC Update

In March 2014 there were three events at two facilities leading to five IJs, all of which were also SSQC.  The first issue stemmed from allegations that the facility did not do enough to prevent residents verbal and physical aggression from a known aggressive resident.  Other residents expressed fear of the subject resident and nursing notes include a long history of verbal and physical aggression, and one noted that reporting the aggression to facility staff didn’t help anything.  Facility appeared to have a good record of interventions with the subject resident (morning meetings, active monitoring and redirection) and the resident’s behavior did improve when he was given an iPad as a redirection tool, however surveyors still took exception with the adequacy of interventions, lack of investigation, and failure to follow policy and procedure.  F223, F225 and F226 were cited for this event.

The next issue was the alleged failure by facility staff to indentify a resident as being “full code” at the time of death and initiate CPR.  LPN discovered the resident after a breathing treatment and stated he had already passed.  CPR was not attempted, and the facility did not have a policy on when not to perform CPR on a full code resident. IJ was lifted when house audit of all charts for code status was performed, CPR verification of all nurses completed, and in-services related to code status, CPR and EMT notification completed.  F309 was cited for this event.

The last issue was the alleged failure of facility staff to supervise a new CNA, working on orientation, to ensure she followed MD orders for a pureed diet. Resident received solid foods, resulting in choking and death.  The CNA was directed to get Jello for the resident, but also to get a different resident a peanut butter and jelly sandwich.  The food was mixed up, and the resident on the pureed diet received the sandwich and was left to eat it unattended.  CNA was also left unsupervised by her preceptor.

A summary of the 2014 IJ/SSQC citations and the March 2567s can be found here.