ISDH IJ/SSQC Update

After issuing no IJ or SSQC citations in January, the ISDH issued one IJ citation in February.  The citation in February was no SSQC.  The citation, F155, was issued due to the failure of the facility to have a system in place to determine code status and failed to perform CPR on a resident who was full code.  The facility also failed to ensure advance directive/code status was clearly documented for 4 of 23 residents reviewed of the total census of 99 residents.  The first issue in the above citation stemmed around confusion between social services and nursing staff about the code status of the patient and the involvement of a guardian that had been appointed upon admission.  Admitting orders indicated that the resident was full code, the CPR consent form indicated no code.  The CPR consent was not dated and it may have been signed by the resident, even though not competent, and it was not also signed by the guardian.  The other 4 residents for which documentation issues concerning code status were identified, problems with documentation ranged from the lack of advance directives with physician orders stating that code had not been established, to unsigned and undated DNR forms, to conflicting DNR forms and physician orders for full code.

February’s citation of F155 marks the 3rd month out of the past 4 months in which a citation has been issued related to errors with determining code status and/or performing CPR on a resident that was or should have been full code.  In November and December 2014, F309 was cited in each month for the failure to obtain code status for a resident then the downstream failure to perform CPR on that resident for which code status was unknown (policy requires CPR to be administered when code status is unknown/not determined).

To review the February 2567 and a summary of the 2015 IJ/SSQCs, click here.