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Based on record review and interview the facility failed to implement an effective action plan when medication errors were identified, and failed to monitor an action plan for sustainability in 2 of 2 adverse events (Patient (Pt) #1, Pt #2), in a sample of 2 adverse events reviewed.

Findings Include:

Review of Pt #1's medical record revealed that during a clinic visit on 02/15/2022 at 11:10 am, Pt #1 was given Bexsero (Meningococcal B) vaccination, per Pt #1's immunization administration record, Bexsero vaccine expired on 01/31/2022 (15 days before administering to Pt #1).

Review of Pt #2's medical record revealed that during a clinic visit on 02/15/2022 at 11:04 am, Pt #2 was given Bexsero (Meningococcal B) vaccination, per Pt #2's immunization administration record, Bexsero vaccine expired on 01/31/2022 (15 days before administering to Pt #2).

Review of an incident report documented by Float Medical Assistant (MA) J on 02/15/2022 (no time), revealed that on 02/15/2022 at approximately 11:00 am, "Two patients, twins, were given Bexsero IM (intramuscular) during nurse visit. Upon documentation of injections, it was noted that the vaccines were expired on 01/31/2022. Provider notified. Pharmacy notified..." Review of the "Brief Factual Description" on the incident report revealed that the "expiration date was not checked prior to administration." Review of the incident report revealed that Medical Assistant D was the "Involved Party" (administered the vaccines).

Review of the "Follow-up Actions" documented on the incident report by Clinic Administrator B on 02/15/2022 at 1:25 pm revealed, "Lead RN (registered nurse) responsible for stocking and clean sweeps of medication rooms states no clean sweep was done for February. Calendar reminders placed to perform clean sweeps of medication rooms at end of month for the next month. Reviewed with clinical staff to document at time of administration. Do not document at desk after giving."

Review of the "Medication Area Inspections" form completed on 02/09/2022 by Registered Nurse (RN) C (Lead) revealed that an "X" was placed in the "YES" column related to "All medications are within their expiration or beyond-use date (check bulk, supplies, refrigerator, freezer, rapid response cart/box, etc.)."

Per interview with Clinic Administrator B on 06/01/2022 at 3:15 pm, in response to incident with Pt #1 and Pt #2, B stated he/she had a "huddle" with the care team and reinforced the process of making sure the expiration date is checked on medication prior to administration and to document vaccine information including expiration date prior to administering vaccines. Per interview, B stated that calendar reminders were sent out to remind staff to complete the clean sweep audits and medication inspections to check for expired medication. Per interview, B stated that no audits are currently being done to ensure the action plan is effective. Per interview with Clinic Administrator B there was no documented evidence of education given to staff (including Float staff).

Interview with RN C on 06/01/2022 at 3:22 pm revealed that RN C was responsible for checking monthly for expired medications in the clinic. Per RN C the Bexsero vaccine was not used as frequently and could have been "overlooked", per RN C the expired vaccines "clearly got missed". RN C stated that medication expirations are checked once per month and the day they are checked "depends"; per RN C, there was no process in place to identify medications that expire before the next monthly check. Per interview with RN C, she/he has not yet received a calendar reminder from Clinic Administrator B in regards to dates of medication expiration checks. RN C stated that she/he "can't remember" if the process for checking expirations was discussed in the "huddle", per RN C she/he is not aware of a new process in place for checking expired medications.

Interview with MA D on 06/01/2022 at 3:50 pm revealed that MA D administered the expired vaccine to Pt #1 and Pt #2 on 02/15/2022. Per interview, MA D stated that he/she was on orientation and training with Float MA J at the time. MA D stated that Float MA J retrieved the vaccine from the medication room and gave the vials to MA D to administer to Pt #1 and Pt #2. MA D stated, "I should have checked the expiration but I felt rushed..." MA D revealed that she/he was going to document the vaccine information prior to administering the vaccines, but Float MA J told her/him to administer the vaccines and MA D can document the vaccine information afterwards (including expiration date). Per interview, MA D stated that he/she does not recall any education given in a huddle by Clinic Administrator B in regards to this incident, MA D stated that he/she does not normally attend the huddles because he/she is typically in with patients at the times of the huddles.

Based on record review and interview the facility failed to ensure that all staff are fully vaccinated in 2 of 12 staff COVID-19 vaccination records reviewed (Food Service Worker F, Rehabilitation (Rehab) Coordinator G) in a total sample of 12 vaccine records reviewed.

Findings Include:

Review of facility policy and procedure titled, "COVID-19 Vaccination" effective date 01/27/2022 revealed the following:
1. All team members are required to be fully vaccinated against COVID-19 or have received an approved exemption.
2. Fully vaccinated means staff must complete a primary vaccinations series for COVID-19 and the 14 day post-vaccination waiting period. The completion of a primary vaccination series for COVID-19 is defined as the administration of all required doses of a multi-dose vaccine

Review of the vaccination tracking list on 06/01/2022 at 12:15 pm with Employee Health H and Infection Prevention I revealed the following:
-Food Service Worker F's start date was 05/11/2022 and she/he received the first dose of the Pfizer COVID-19 vaccine on 05/05/2022. Per review of the vaccine tracking list, Food Service Worker F had not received the second dose of the vaccine at the time of review.
-Rehab Coordinator G's start date was 03/29/2022 and she/he received the first dose of the Pfizer COVID-19 vaccine on 03/25/2022. Per review of the vaccine tracking list, Rehab Coordinator G had not received the second dose of the vaccine at the time of review.

Per interview with Employee Health H at the time of the above review, H stated that Food Service Worker F and Rehabilitation Coordinator G have not received their second dose of the Pfizer vaccine and do not have a medical or religious exemption. Per interview with Employee Health H, Food Service Worker F and Rehab Coordinator G were allowed to work with just one dose of the vaccine so that the onboarding process would not be delayed.