HospitalInspections.org

Based on review of patient records, facility provided documentation, policies/procedures and staff interview, the facility failed to ensure heparin that was ordered for one of 10 patients (#8) reviewed was administered in accordance with the established protocols approved by the medical staff and that medication ordered to be discontinued was not given after the order for Patient #9.

The findings include:

1. Patient #8 was admitted to the facility on 12/8/10 with a diagnosis of acute renal failure and Heparin was ordered on 12/16/10. The heparin was ordered for bilateral upper extremity DVTs. The facility policy states that two nurses shall check the calculations for the administration, and that the dosage is weight based. Although two staff members did do the calculation, they did not have the actual patient weight. The weight on the medical record was from an estimated weight from the emergency department, and the patient was not weighed when admitted to the unit. The weight from the emergency room was 87.9Kg and the actual weight was 53Kg. The patient received an overdose of the medication and was sent to ICU due to changes in condition.

Review of the policies and procedures revealed that any patient that is on heparin is to have neuro checks per routine. A review of this noted that "routine" is different depending on the unit the patient is on. Routine checks can be from every two hours to every 8 hours which may cause a delay an assessment showing change in condition to the patient.


2) Patient(#9), was admitted through the emergency department on 12/15/10 with increasing shortness of breath. The patient was also noted to have Stage 4 renal failure. The patient was receiving dialysis in the facility as an inpatient. It was noted that a consultation was done by a hematologist on 12/22/10 at approximately 1700. The reason for the consult was for some bleeding from the newly placed dialysis catheter site as well as a nose bleed the previous night.

The impression/plan that was written stated that the bleeding around the catheter and the nose bleed was most likely related to the heparin use during dialysis and possible exacerbated by a uremic-induced platelet dysfunction.

An order was written to stop the heparin during dialysis on 12/22/10 at 1236. The patient did not receive dialysis on that day. The order was noted and a note put on the patient flowsheet for dialysis, but per interview on 12/29/10 with nursing management, the dialysis nurse did not see it. On 12/23/10, when the patient received dialysis, there was a one time dose of 1000 units of heparin given with the treatment. The patient had another treatment on 12/24/10, and no heparin was given at that time.

Based on patient and facility record review, and interviews with nursing and pharmacy staff, the facility failed to supervise the dispensing of medication for one of twelve patients reviewed (# 8).

The findings include:
A review of the medical record for Patient #8 revealed that the patient was admitted to the facility on 12/8/10 with a diagnosis of acute renal failure and Heparin was ordered on 12/16/10. The heparin was ordered for bilateral upper extremity DVTs. The facility policy states that two nurses shall check the calculations for the administration, and that the dosage is weight based.


Two nurses calculated the rate to be given the rate without any review by the pharmacy department. Due to a miscalculation of the rate to be used on the patient, the total given to the resident was higher than the physician ordered or per protocol. The pharmacy review of this procedure was limited to the drug and any contraindications for its use. The rate calculated by nursing was incorrect due to using an erroneous use of an estimated body weight rather than the patient's actual weight. The pharmacy was not involved in a review of the calculated weight.
Interviews with the nursing and pharmacy managers on December 28, 2010 at 2:00 pm., confirmed that the current procedures for the rate calculation do not include a review by the pharmacy department.