ISDH IJ/SSQC Update

In the month of August 2014 there were two events that were both IJ and SSQC, leading to 4 tags being cited.

The first event involved allegations of verbal, physical, and mental abuse of a resident that were not thoroughly investigated and for which the facility’s policies and procedures were not followed, for which F223, F225 and F226 were cited.   The issue stemmed from a resident being given a shower against her will, and the resident’s complaints to other staff members of being given a shower against her will and the staff’s failure to immediately report allegation of abuse to the administrator.  The resident had experienced a large bowel movement overnight and was in need of a shower, even though it was known she did not like them.   The DON determined that it was in the resident’s best interest to receive a shower and, even though the resident was known to be difficult (though documentation was lacking on this point), the staff was directed to give the resident a shower.  During the shower the resident complained of the water temperature being too  hot and scalding and the verbal abuse of staff. 

The second event involved the alleged failure of a facility to prevent progress of a pressure ulcer that developed into a stage 4 ulcer, for which F314 was cited.  Upon review of the clinical record, the ISDH took issue with the facility’s failure to provide treatment to the ulcer twice daily as ordered by a physician.  The clinical record lacked documentation to support physician ordered treatment.

To read the 2567s from August and for a summary of the 2014 IJ/SSQC citations, click here.