Failure to Rotate Injection Sites for Heparin Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the improper administration of Heparin injections to a resident. The resident, who had a diagnosis of Functional Quadriplegia and an intact cognitive status, was receiving Heparin subcutaneously twice daily as a prophylactic measure. However, the nursing staff did not rotate the injection sites as required by the facility's policy, leading to repeated injections in the same area of the lower left abdomen. This was confirmed through a review of the Medication Administration Record, which showed multiple instances of consecutive injections in the same site over several days. During an observation, the resident was found to have a quarter-size ecchymosis on the lower left abdomen, indicating potential tissue damage from the repeated injections. Interviews with the nursing staff and the Director of Nursing Services confirmed that the injection sites were not rotated as per the policy, and the nurse responsible could not provide a reason for this oversight. The physician also acknowledged that failure to rotate injection sites could result in bleeding, pain, and tissue damage, further highlighting the deficiency in adhering to professional standards of care.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F658. Resident #20 was reassessed by RN supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated ON 2/26/2025 to include rotating sites with each administration. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON and no updates were made. All Nurses were re-educated on 3/01/2025 by DON/Designee on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months on all residents on [MEDICATION NAME] to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.