Inappropriate Medication Administration via PEG Tube
Penalty
Summary
The facility failed to ensure the appropriate administration of medications via a percutaneous endoscopic gastrostomy (PEG) tube for a resident, identified as R73. During an observation of medication administration, an LPN was seen preparing and administering nine crushed medications through R73's PEG tube. The process involved an initial water flush of 30-40 milliliters, followed by the administration of medications with varying amounts of water flushes between them. The orders indicated a flush amount of 20-30 milliliters, but the facility's policy required a flush of 15 milliliters between medications. The LPN combined the last five medications, which was not ordered for R73, and administered them together, leading to the resident feeling full and nauseous. Interviews with facility staff, including another LPN, the Unit Manager, and the Director of Nursing (DON), revealed inconsistencies in the understanding and application of the facility's policy on PEG tube medication administration. The staff reported different practices regarding the amount of water used for flushing between medications and the combining of medications, which contradicted the facility's policy. The facility's policy required medications to be diluted with at least 30 milliliters of water and flushed with 15 milliliters of water between medications unless otherwise prescribed. This inconsistency in practice and deviation from the policy led to the deficiency in the care provided to R73.
Plan Of Correction
Element 1: It is the practice of the facility to ensure an appropriate amount of water flush is provided between administration of individual medications via peg tube. Element 2: Residents that receive medications via peg tube have the potential to be affected by this cited practice. R73 stated she was fine and that she always feels full. R73 was offered to take her medications by mouth and stated she prefers her medication via peg. LPN E was educated on medication administration via peg tube. Element 3: The Interdisciplinary Team reviewed the policy and procedure on Enteral Tube Medication Administration and deemed it to be appropriate. Nursing was educated on Enteral Tube Medication Administration. Element 4: Nurse Educator/Designee will audit random nurses weekly x4 for proper medication administration via peg, then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5: The Administrator will be responsible for sustaining compliance.