ISDH IJ/SSQC Update

In December 2014 there were 3 events leading to 3 IJ citations, all of which were SSQC, and 2 additional SSQC citations.  Also, a 23-day revisit took place in December for an IJ that occurred in November 2014.  The first issue involved an allegation of abuse that the ISDH indicated was not thoroughly investigated and reported to the ISDH.  The ISDH also indicated that the facility did not suspend the suspect employee and failed to follow their policies and procedures related to abuse investigations.  The issue resulted in citation of F225 and F226 at scope and severity J.  The issue involved a visitor overhearing an RN tell a resident to “shut up” and the resident replying “you b*****d nurse, you hit me.”  The visitor, who was a family member of another resident, did not witness anything and did not report this to the DNS until a week later.  The family member also said she saw some bruising on the resident’s face.  Already documented in the resident’s file was information about the facial bruising as a self-inflicted injury, as the resident has exhibited self-injurious behavior in the past.  Nevertheless, the allegation by the family member was not investigated or reported to the ISDH separate and apart from the prior documentation about the resident’s bruise.

The second issue in December also resulted in citation of F225 and F226, but at the scope and severity F.  A CNA heard noises coming from two residents’ room and entered to find one resident over the top of the other and blood on the injured resident’s face, arms, and hands.  The injured resident was treated and taken to the ER for further evaluation, then returned to the facility about 4 hours later.  There was no documented history of incidents between the two roommates, but during interview with an RN the ISDH was told that the RN had heard a rumor that the aggressor roommate had been groping the injured roommate.  The RN did not witness anything nor could indicated when or where she had heard this.  During interview with the Administrator it became known that the Administrator had been aware of an allegation of groping based on a family member’s statement about a bit more than a week before the injury took place.  The facility was cited for failure to investigate the allegation of groping and follow their policies and procedures concerning allegations of abuse.

The third issue in December involved a resident that had not executed an advance directive upon admission, then was later found without pulse and respirations and CPR was not immediately initiated.  While CPR was initiated prior to emergency services arriving at the facility, it was not initiated immediately and only was after the interim DON directed it to be done.  Notifications to the MD, family, and 911 were done correctly, but the CNA and LPN did not treat the resident as a full code, which is what should occur for a resident that has not execute an advance directive.
To review the December IJ and SSQC citations and a summary of all 2014 IJ and SSQC citations, click here.