ISDH IJ/SSQC Update

There were two events in November 2014 that led to two IJ citations, both of which were SSQC.   The first issue stemmed from the admissions nurse failing to record code status of a resident upon admission, which led to CPR not being initiated for that resident about 14 hours after being admitted.  This resulted in death and a F309 citation.  The resident had been admitted from the hospital for rehab due to a hip fracture.  The hospital records indicated the resident did not have advance directives paperwork, but was noted as full code in the hospital chart.  Upon admission the resident’s code statues was not completed and the resident was sent back to the hospital the same afternoon she was admitted to the facility due to a leaking gastronomy tube.  When the resident returned to the facility that evening, the code status was still not completed.  Overnight the resident was found without respiration and pulse and the LPN that found the resident did not initiate CPR, even though the facility’s policy is to treat all patients as full code if their code status is unknown to the caregiver.  The event was cited as past-noncompliance.

The second event related to the worsening of pressure ulcers, one of which was known to staff and another that was acquired at the facility.  IN addition, the facility had failed to ensure skin risk assessments had been completed for 4 of 5 residents reviewed.  This resulted citation of F314.  The ISDH surveyor noted, for both pressure ulcer issues and documentation issues, that assessment and reassessment of ulcers was not performed consistently and orders for treatment of pressure ulcers were at best not documented and likely not performed as ordered.

Click here to access the November 2567 and for the 2014 IJ/SSQC Summary.