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Date ArticleType
2/2/2016 Regulatory
IJ/SSQC Citation Update

There were 4 IJ citations issued by the ISHD in the month of December. Two Citations were issued for F 323. In the first situation, the facility failed to ensure adequate supervision was provided for a cognitively impaired male with a history of behaviors including, but not limited to, wondering into other resident rooms, exposing himself and touching staff members inappropriately. The lack of supervision resulted in the resident entering the room of a dependent and cognitively impaired female resident. The female resident was observed on the floor, and unclothed. In the second citation for F 323, the facility failed to ensure a resident who was established as known elopement risk was provided adequate supervision to prevent elopement which resulted in the resident leaving the facility through an alarmed door. The event was related to the failure of the staff to complete every 2 hours observation rounds and the failure to ensure staff followed protocol by turning off the alarming exit door and not notifying other charge staff when no residents or staff members were observed outside of the exit door. The resident was discovered missing 3 hours and fifteen minutes after last being seen. F 323 has been cited on six occasions in 2015 and three were related to cognitively impaired residents and elopement.

There was one IJ citation issued for F 224 in December, 2015 for failure of the facility to ensure a resident's care was not neglected related to, not implementing new interventions when a resident's food and fluid intake decreased, The resident exhibited increased swallowing problems, and the facility did not follow Speech Therapy's recommendation of notifying the family for directions on alternate ways for food and fluid consumption and did not notify the resident's Physician and Health Care Representative (HCR) in a timely manor of the decrease in food and fluid intake. The forth IJ citation was for F 309 when the facility failed to ensure necessary services, including assessments, observations, and safety interventions were implemented for a resident with a venous access fistula (an implanted device to allow access for dialysis) who was identified as at risk for bleeding from the fistula and who suffered a fatal loss of blood from the fistula site. 

To review a summary of the 2015 IJ/SSQC, click here. If you would like to have more details related to the above citations, email Lori Davenport at ldavenport@ihca.org.