There was one IJ citation issued by the ISHD in May. F 155 was issued for failure to ensure a resident’s right in self-determination regarding implementation of the formulated advance directive and staff failed to initiate CPR as indicated. This is the third time F 155 has been cited as the IJ level in 2015, and the fifth time in the last 7 months that a citation has been issued at the IJ level for failures surrounding advance directives and administration of CPR. In the May event, the resident was found lying on the floor and had clearly passed on. The resident was totally purple in the upper body and was still slightly warm to the touch. No pulse, blood pressure or respirations were noted. However, the resident was full code. The RN in charge at the time indicated that the chart was not checked for code status as she felt there was no effort that could bring the resident back. Even if the resident was not full code, which she was, the facility has a policy that requires resuscitation efforts, via an AED, unless a valid Advance Directive or DNR order states not to. This citation was past-noncompliance and the IJ was lifted after a complete audit for code status was performed, all staff were inserviced on code response, two mock drills were performed, staff involved in resuscitative efforts were CPR certified, and education and disciplinary action were taken with the RN.
To review a summary of the 2015 IJ/SSQCs and the May 2567, click here.
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