Failure to Rotate Injection Sites for Heparin Administration
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident by not adhering to professional standards of practice for administering medications. Specifically, Resident #21 was prescribed Heparin Sodium Injection Solution and the nursing staff did not rotate the subcutaneous injection sites as required. The facility's policy and procedure for injection site rotation, as well as professional guidelines, emphasize the importance of rotating injection sites to prevent complications such as bruising. Resident #20, who was admitted with functional quadriplegia and had an intact cognitive status, received Heparin injections to the same site on the lower left abdomen over multiple days. This was documented in the Medication Administration Record for January and February 2025. During an observation, a quarter-size bruise was noted on the resident's abdomen, and the resident confirmed they did not monitor the injection sites. Interviews with the nursing staff and the Director of Nursing Services revealed that the injection site was not rotated as required, which could lead to tissue damage and discomfort.
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. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F755. Resident #20 was reassessed by the 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. 2. 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. 3. 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/Designee and no updates were made. All Nurses were re-educated on 3/01/2025 by the DON 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. 4. 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 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 consultant pharmacist will monitor externally for appropriate site rotation based on administration records and will report negative findings to DON. 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.