ISDH IJ/SSQC Update

There were four events in September leading to four IJ citations, three of which were also SSQC.  The first issue involved the failure of a facility to put in place appropriate interventions to prevent non-consensual sexual contact between two residents with diagnoses of dementia, and known wanderers, amongst other issues.   F323 was cited when the male resident was transferred to a psychiatric unit for evaluation and the female resident was placed on 1:1 care with 15 minute checks.  The male resident was found undressed in his room (which according to his care plan is normal for when he was sleeping) and the female resident wandered into the male resident’s room.  The male resident was reported to have his hand up the female resident’s gown.  A staff investigation occurred, including medical examinations of the female resident, and the staff did not find any abuse, however there was uncertainty concerning the consensual or non-consensual nature of the contact.  Due to cognitive status surveyors determined this to be non-consensual sexual contact.

A second F323 citation was issued for failure of a facility to provide supervision and interventions to reduce risk of harm to other residents to a resident who was a known wanderer and that had a history of physical and verbal abuse.  Several residents reported that they were afraid of the resident in question.  The surveyors noted that the resident had been in a dementia unit before and the resident’s daughter was aware of the behavior, however the SSD indicated that the family member had not been contacted prior to survey about placing the resident on a secured dementia unit.

A citation was also issued for F414 for the facility’s failure to ensure proper sanitation procedures for the cleaning of reusable glucometers.  The staff mistakenly used non-manufacturer approved, or non-bleach based, wipes for cleaning the glucometers.   Also in September, F314 was issued concerning failure to prevent development of a State 4 pressure ulcer (this tag was reported last month as well as it was included in the August report even though it occurred on September 2).

Click here for a summary of the 2014 IJ/SSQCs and for the September 2567s.