ISDH IJ/SSQC Update

There were 6 events in May that were cited as IJ, all of which were also SSQC.  In total, 9 tags were cited as part of the 6 events.  This is the highest number of IJ/SSQC events since August of 2011, and the highest number of IJ/SSQC tags in a month since September of 2011. 

Two of the six events in May were related to resident elopement.  In one of those events, a resident briefly eloped that had been identified as an elopement risk and required monitoring for “tailgating” visitors who were entering or exiting the building.  This resident was standing by the doors of a facility and exited when a visitor entered the facility.  The second elopement issue concerned an unsecured window in the front of the facility that was left open as it was used to promote ventilation in the facility.  It appears the window was open overnight and the resident used the open window to leave the facility.

Citations were also issued in May for two events dealing with alleged sexual assault of a resident.  In one event the facility was cited for failure to ensure the facility staff reported a reasonable suspicion of a crime to law enforcement according to the Elder Justice Act, and in conformity with facility policy.  After discovering bruising of unknown origins during a routine skin assessment, the LPN immediately contacted the DON and then the Administrator of the discovery.  The LPN did not report to the policy as she was told by the DON and Administrator not to do so as they would be coming to the facility to deal with the situation.  After an internal investigation took place police were called until approximately 13 hours after the LPN’s discovery.  Based on the location and extent of bruising police investigators indicated this was certainly enough to form a reasonable suspicion of a crime, and it was ultimately called into police within the 24 hour window for injuries other than serious bodily harm (in certain circumstances sexual abuse can be deemed serious bodily harm/injury).  This event serves as a reminder that while facilities are permitted to help coordinate the reporting of reasonable suspicions of crimes to law enforcement, the policies on such practice should be clear and known to staff and should not discourage staff from making their own report if they want to do so.  This incident appears to have been otherwise immediately reported to the ISDH as an incident, however the ISDH appears to also have taken exception to the manner of the investigation conducted by the facility in that no male staff were interviewed as part of the process and the collection of the resident’s clothing was haphazard and not helpful to the separate police investigation.  In the second event concerning alleged sexual assault, a LPN witnessed a CNA pulling up their pant quickly as the LPN entered the room where the CNA was with a patient.  For this issue, the ISDH cited the lack of immediate reporting by the LPN to the Administrator per facility policy as the LPN did not notify the Administrator until 4 hours after witnessing the event.  The ISDH did not cite any failures with respect to the Elder Justice Act.

The last two events in May concerned PT/INR monitoring for a resident on Coumadin therapy, and another concerning the lack of clarification upon admission of the ordering of three anticoagulants for a resident.  Each issue results in hospitalization of the resident.

To view the May 2567s from the ISDH  and a summary of the 2014 IJ/SSQC events and citation, click here.