April ISDH IJ/SSQC Report

There were two events in April that led to 2 IJ citations, one of which was also SSQC.  The 2567s of April’s IJ/SSQC citations can be found in the Members Only section of the IHCA website, as is a summary chart for 2013.

The first, an F323 tag that was cited by Federal surveyors after a complaint, related to a physically and verbally aggressive male resident, and the 5 other residents that were impacted by his behaviors.  The residents, a child in a children’s facility, was extremely aggressive towards staff and other residents that could not defend themselves.  Since his admission 2/18/13 and through March, the facility had logged 79 aggression incidents, 121 cussing incidents, and 15 resistant to care incidents.  The resident was prescribed Seroquel and diagnosed bipolar, in addition to other diagnoses, but the mother refused the medication and the diagnosis.  The physician’s services were discontinued at that time by the mother.  The IJ was removed when the facility issued 30-day notice of discharge along with continuous one-on-one and/or two-on-one supervision until discharge, provided psyhocsocial assessments on the other 5 impacted residents, reviewed and updated care plans, initiated staff education on behavior recognition that may affect other residents, and daily review of behavior reports and nursing notes. 

The second, an F441 tag was cited due to surveyor observation of improper disinfection practices on a blood glucometer.  During one observation, an RN used a blood glucometer without having cleaned it first, then after the use the RN did clean it with a Clorox wipe.  The facility policy called for the blood glucometer to be cleaned with a Clorox wipe prior to and after each use.  The surveyor noted that Clorox wipes are not effective in disinfecting blood borne pathogens, which was confirmed in a discussion with a Clorox representative. In a second observation, an LPN used the blood glucometer and returned it to the cart without cleaning it.  During interview with the DON, the DON indicated there had not been any in-services regarding blood glucometer disinfection practices.
Through April of 2013 there have been 5 IJ citations issued and 6 SSQC citations, which is about half of the 2012 totals for the same period (13 IJs and 10 SSQCs), IJs are down more than half as compared to the same period in 2012.  F323 continues to be the most cited tag during IJ/SSQC events with 3 so far in 2013 (4 tags through April of 2012, and 3 in 2011).  The downturn in IJ/SSQC citations so far this year continues a downward trend that began in 2012 as compared to 2011.