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Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to obtain a patient's weight prior to the administration of a weight-based anticoagulation medication. This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.
A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP6, EMP8, EMP9, EMP10, EMP11, EMP 13) regarding the survey team's concerns related to Nursing Services on November 7, 2024, at approximately 3:47 PM.
On November 8, 2024, the survey team reviewed facility documents, education logs, audit logs, and interviewed staff to determine compliance for the removal of the Immediate Jeopardy.
The survey team verified these immediate interventions were implemented and confirmed the facility's Immediate Jeopardy was removed on November 8, 2024 at 1:30 PM
Cross reference:
482.23(c) Nursing Services: Preparation and Administration of Drugs

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to maintain a safe environment for patients receiving anticoagulation medication by failing to follow facility policy for obtaining patient weights on admission and when placed on a weight-based medication as evidenced in one (1) of ten (10) MRs reviewed (MR1)
Findings include:
Review on November 7, 2024, of facility policy "Weights Policy and Procedure" , dated March 20, 2022, revealed "...Policy ...2.Nursing personnel obtain and document a patient's weight upon admission, when the patient is placed on a cardiac or telemetry monitor with a daily weight order, when ordered by a licensed independent provider (LIP), and when the patient has been prescribed a weight-based medication ...Procedure.2.Weighing patients on high alert weight-based medications: ...b. A current weight is to be obtained to ensure accuracy of medication dosing. C. When weighing a patient for administration of a high alert weight-based medication, prior to administration and at the time of the 2-Nurse independent double check, it is important to note when the nurse is validating that the dose is correct, the nurse understands the dose is based on obtaining and entering the correct weight. This means the nurse is secure in the accuracy of the patient's weight provided to the pharmacy."
Review on November 7, 2024, of MR1 revealed the patient was admitted on October 1, 2024 with a diagnosis of Right-sided frontal acute subdural hematoma.
Further review of MR1 revealed an order for enoxaparin injection at a dose of 0.5mg/kg to be given subcutaneous every twelve (12) hours starting October 3, 2024 at 8:00 AM. Review of order's dose calculation revealed:
"...0.5mg/kg x 125 kg (Weight as of 10/2/2024)
= 60 mg (changed from 62.5 mg to standard dose)
= 60 mg x 0.6 ml/60 mg
= 0.6 mL x 60 mg/0.6 mL
= 60 mg
Admin Dose: 60 mg ..."
Continued review of MR1 revealed that a weight of 125 kilograms (kg) was recorded on October 2, 2024 at 9:00 AM. Review of the medication administration record revealed that the patient received 60 milligrams (mg) of enoxaparin subcutaneously on October 3, 2024 at 9:25 AM and 8:21 PM in the right lower abdomen. Additional review of MR1 flowsheet documentation revealed another weight of 59.1 kg documented on October 4, 2024 at 12:00 PM.
Interview on November 7, 2024 at 11:25 AM with EMP5 confirmed the facility determined the pharmacist called the nurse assigned to the patient (MR1) in the ICU and asked for a weight of the patient. Further interview confirmed the nurse assigned to the patient took the weight from the patient's previous admission, which was 125 pounds (lbs). EMP5 further confirmed the nurse did not weigh the patient. The nurse then entered the patient's weight in MR1 as 125 kilograms (kg), instead of 125 pounds.
Interview on November 7, 2024 at 11:30 AM with EMP3, confirmed a patient weight was not obtained on admission to the ED, on transfer to the ICU, or on transfer to the Medical Surgical unit as was required by facility policy.
Interview on November 7, 2024 at 12:01 PM with EMP2, confirmed that a physician assistant had sent a secure message to the nurse caring for the patient on October 2, 2024, at 12:21 stating that the they thought the weight was entered wrong and requested for the weight to be checked. The nurse replied with a 'yes' but the facility determined a weight was not obtained. EMP2 also confirmed that there was no order entered for a weight check.

Cross reference:
482.23 Nursing Services