Failure to Rotate Enoxaparin Injection Sites as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was prescribed enoxaparin sodium injections for DVT prophylaxis. According to the physician's order, the injection sites were to be rotated, and the facility's policy and procedure for subcutaneous injections required licensed nurses to verify the order and rotate injection sites to ensure proper administration. Medical record review revealed that the injection sites for the resident were not rotated as required, with multiple consecutive injections administered to the same area of the abdomen over several days. Interviews with nursing staff, including an LVN and an RN, confirmed that they were aware of the need to rotate injection sites and that the physician's order included this instruction. Both staff members reviewed the medication administration records and verified that the injection sites had not been rotated. The DON also confirmed that the facility's policy was not followed in this instance. The failure to rotate injection sites was directly observed in the documentation and acknowledged by the staff involved.