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Date ArticleType
12/3/2015 Regulatory
IJ/SSQC Citation Update

There were five events in October that resulted in the ISDH issuing five IJs and four SSQCs.

• A facility received Tag F223 (SS=J), when the facility failed to ensure sexual abuse by a staff member did not occur toward 3 of 6 residents reviewed for sexual abuse resulting in mental anguish. Immediate Jeopardy began on 9/18/15 when a resident indicated she had been inappropriately touched by a male CNA, who then exposed himself to her and attempted to have the resident touch him. The resident informed another CNA of the incident on 9/19/15 and the facility launched an immediate investigation, following the facility and State’s policy. The investigation revealed both a male and female resident had a sexual encounter with the same CNA. The facility terminated the CNA on 9/21/15 and filed a “Consumer Complaint” to the State Attorney General’s Office regarding the incident and licensure of the CNA. The IJ began on 9/18/15 and was removed on 9/21/15 when the facility terminated the employee, completed their investigation, notified ISDH Long Term Care Division, notified local law enforcement, State Attorney General’s Office, completed staff inserviced education and residential/family education on abuse/abuse prohibition. Post-inservice interviews were also conducted to make certain staff and residents understand protocol in abuse situations. The IJ was removed before the Administrator was even aware of it.

• A facility received Tag F223 (SS=K), Tag F225 (SS=L), and Tag F226 (SS=L), when the facility failed to ensure residents were free from verbal and mental abuse when a CNA who was verbally and mentally abusive to residents was not immediately removed from resident care, resulting in psychosocial harm to 4 of 20 residents reviewed for allegations of verbal and mental abuse. Immediate Jeopardy began on 3/6/15 when a resident indicated that a CNA threatened to smother the resident with a pillow while sleeping. Between the incident triggering the IJ in March and the CNA being suspend on 9/20/15, there were three additional abuse allegation incidents reported to the facility administration. Only the last incident resulted in the CNA being suspended for investigation. All other allegations were not properly reported or investigated, which is how the facility received Tag F225. Tag F226 was issued for the facility failing to implement policy regarding abuse. The IJ that began on 3/6/15 was removed on 10/8/15 when the facility inserviced all staff regarding abuse and abuse reporting requirements.

• A facility received Tag F224 (SS=J), when the facility failed to ensure a resident with an intellectual disability, who required supervision and assistance with ADL’s, was free from neglect. This is related to the facility discharging the resident to the community without proper discharge planning, lack of home health services, no social service interventions for mental health therapy, and without permission of the Legal Guardian. On 9/28/15 the resident was transferred from the facility to guardian’s care, the same guardian that placed resident in the facility due to lack of being able to provide adequate care to the resident. The facility indicates that the guardian understood and agreed to care for the resident. The guardian indicates that the facility did not contact her and if they did, she would not have agreed to take back the resident. The IJ that began on 9/28/15 was removed on 10/16/15 when the facility inserviced administrative staff, nursing, and social services on Post Discharge Plan of Care, documentation of all efforts, and what efforts should be taken if the facility was unable to meet the resident’s needs. For future discharges the Administrator will be responsible for notifying the Regional Director and/or Nurse Consultant before all prospective discharges from the facility for review. Continued compliance with the safe and appropriate discharge and transfers will be reported to the monthly Quality Assurance Committee.

• A facility received Tag F155 (SS=J), when the facility failed to have a system in place to determine code status for 2 of 2 residents that did not receive CPR, but did not have DNR code. The Immediate Jeopardy began on 8/2/15 when a resident was found in bedroom by LPN with no evidence of vital signs. The LPN could not locate resident’s Advanced Directive and called resident’s physician. LPN states physician instructed resident is DNR and no CPR was performed. The resident, did however, have a full code note signed and dated from physician’s nursing home/assisted living facility visit on 7/16/15.

On 9/8/15 a resident’s DNR was signed by physician, but the resident died on 9/7/15. The resident was found in room, by the same LPN from the first event, showing no evidence of vital signs.  LPN indicated that resident was in hospice and most hospice residents do not receive CPR, so the LPN did not even check resident’s code. Resident received full cardiac code on 8/16/15. The IJ began on 8/2/15 and was removed on 10/8/15. The facility has reviewed current procedure on how to properly assist a resident that does not have Advanced Directives or POST. On 10/6/15 the DON updated the policy to instruct staff members to initiate CPR in the event a resident is found unresponsive.

• A facility received Tag F323 (SS=J), when the facility failed to ensure supervision and safety interventions were implemented to prevent the elopement of 1 of 3 residents known to be an elopement risk. On 10/15/15 the resident eloped from the facility without anyone noticing for over 12 hours. The resident was to receive a Roam Guard to monitor the resident in the event that the resident attempts to escape, an alarm will sound and the doors will lock. The resident never received a Roam Guard. There was stated confusion between staff as to the location of the resident and if he was out with family. Once the resident had not returned by 11:45 pm, a LPN notified the ED of the resident’s disappearance. The ED instructed the LPN to contact the resident’s family to see if they knew resident’s whereabouts. The family did not and the ED initiated an external premises search and contacted local law enforcement. The IJ began on 10/14/15 and was removed on 10/20/15 when the facility educated staff on elopement policy and procedure.

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