By Charlotte Huffman
MANNINGTON Twp., NJ (CBS) -- A Salem County immunization clinic is shut down after children were given the wrong vaccines.
The immunization mix ups happened from June 30, 2014 through July 1, 2015 at Salem County Health Department's "Shots for Tots" clinic, which provides free vaccinations to the uninsured.
An annual compliance audit completed by the state in mid-June noticed irregularities involving clinic operation, patient records, vaccine storage and medication dispensing.
That discovery led to a subsequent county investigation which revealed the clinic administered the incorrect medications to five children.
County officials say "the most egregious medication dispensing case" is that of a two-year-old boy who received an "excessive dose" of Gardasil, a vaccine used to prevent cervical cancer.
"It is an inappropriate medication obviously for a two-year-old and it was given in a double dosage," said county attorney Michael Mulligan on Monday.
"Gardasil administration to someone of tender years can present a problem with regard to neurological development," he said.
In addition to the two-year old boy, the county's investigation found two children received expired vaccines. One child received a vaccine despite being under the recommended age. Another child was vaccinated incorrectly, but county officials are still trying to determine what kind of vaccine was administered to the child.
The report says the two-year-old's mother and pediatrician were notified of the incident on June 30th and families of the four other children have also been notified.
Whether the children will experience health effects is not yet known, but the county has agreed to pay the medical bills to monitor the children "for the foreseeable future."
The audit also found that vaccines with an estimated value of $20,000 were improperly refrigerated and determined unsafe for distribution and destroyed.
"Medication errors cannot be tolerated," said Mulligan who plans to recommend that the county's clinic remain closed permanently.
Officials say the two registered nurses who ran the clinic at the Memorial Hospital of Salem County are Mandi Cassidy and Nikole Johnson, both of Salem County.
Cassidy and Johnson have resigned from their full time positions with the Salem County Health Department, officials said.
Neither Cassidy nor Johnson were available Monday for comment.
Over the past year, the clinic only vaccinated 22 people, including the five children.
"With the high level of errors that occurred it is probably something we shouldn't be doing," said Mulligan.
"Shots for Tots" has been located at the Memorial Hospital of Salem County for approximately 25 years.
A spokesman for The Memorial Hospital of Salem County released the following statement:
"The Memorial Hospital of Salem County has no medical oversight for the clinic and the vaccinations. The hospital only provides space for the monthly event free of charge to the Salem County Health Department." does not have medical oversight of "Shots for Tots."
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