The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LITTLE COMPANY OF MARY HOSPITAL 2800 W 95TH ST EVERGREEN PARK, IL 60805 Sept. 7, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 2 of 3 (Pt #2 and 10) clinical records reviewed of patients receiving an anticoagulant, the Hospital failed to ensure the medication was administered as required.

Findings include:

1 The clinical record of Pt #2 was reviewed on 9/6/16 at approximately 11:00 AM. Pt #2 was a [AGE] year old male admitted [DATE] with a diagnosis of morbid obesity. Pt #2's clinical record contained a physician's order dated 8/29/16 that required, "Lovenox 40 mg (milligram) SQ (subcutaneous) daily." Pt #2's clinical record contained documentation that the medication was administered in the patients arm: 9/3 RTA (right arm); 9/4 LTA (left arm); 9/5 RTA; and 9/6/16 LTA.

2. The clinical record of Pt #10 was reviewed on 9/6/16 at approximately 12:45 PM. Pt #10 was an [AGE] year old female admitted on [DATE] with a diagnosis of bowel obstruction. Pt #10's clinical record contained a physician's order dated 9/4/16 that required, "Lovenox 30 mg SQ daily. Pt #10's clinical record contained documentation that on 9/4 and 9/5/16 the Lovenox was administered in the left abdomen and not alternated as required and on 9/6/16 the medication was administered into Pt #10's left arm.

3. The Outcomes Coordinator and 7 West Unit Manager stated during interviews on 9/6/16 at approximately 11:10 AM and 12:45 PM that Lovenox should not be administered in the arms or legs.

4. Hospital in-service poster entitled, "Giving Lovenox? Think Love-Handles," located on 7 West (undated) included, "...It should be given in the abdominal wall... the area known as the 'love handles' which is roughly 2-3 inches to the right or left to the umbilicus...Document ABDOMEN as the site...but add ANT LAT or POST LAT (R) or (L) as a comment if you can."

5. The drug insert for enoxaparin sodium (Lovenox) injection dated 2014 was reviewed on 9/6/16 at approximately 1:30 PM. The insert indicated, "...2.4 Administration...Enoxaparin sodium must not be administered by intramuscular injection...Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall."