Failure to Correct Medication Administration Route for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to adhere to professional standards of practice in the transcription and administration of medication orders for a resident with a gastrostomy tube. The resident, who had a history of dysphagia following a nontraumatic subarachnoid hemorrhage, was on an NPO (Nothing by Mouth) diet, with all nutrition and medications to be administered via the gastrostomy tube. Despite this, several medications were ordered and documented to be administered orally (PO), and staff signed off on these orders as if they were administered by mouth. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that they were aware of the resident's gastrostomy status and that all medications were indeed administered via the gastrostomy tube. However, the orders were not corrected to reflect the appropriate route of administration, and the staff did not seek guidance to amend the orders, which is a requirement when care needs exceed the LPN's scope of practice. This oversight in ensuring the orders matched the resident's care needs led to the deficiency.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 144's orders were changed after contacting the physician to administer medications through gastrostomy tube. 2. To identify other residents that have the potential to be affected, the DON/designee conducted an audit on NPO residents to ensure physician orders are accurate for the method the resident is administered their medications. 3. Licensed staff will be educated by staff development/designee on accurately entering orders into the EMAR and medication administration. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admitting NPO residents and any new medication orders for NPO residents to ensure the physician orders are correct in regards to the method the medication is administered to the resident. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.