Failure to Flush G-Tubes Between Medications Results in High Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 15.38% based on four medication errors out of 26 observed opportunities. The errors involved two residents who were dependent on staff for activities of daily living and had gastrostomy tubes (g-tubes) for medication and nutrition administration. Both residents had physician orders and care plans specifying that their g-tubes should be flushed with water before and after medication administration, as well as between medications, to maintain tube patency and ensure proper medication delivery. In the case of one resident, a nurse administered crushed Keppra mixed with water via the g-tube, followed by additional water to flush the remaining medication, and then administered crushed fluconazole. The nurse did not flush the g-tube with water between the two medications, contrary to facility policy and the resident's care plan. A pharmacist interview confirmed that administering Keppra and fluconazole in this manner could have moderate drug interactions, and the facility's policy required flushing between medications to prevent such issues. For another resident, a nurse administered liquid Colace followed by crushed Urecholine mixed with water through the g-tube without flushing the tube in between the two medications. The nurse acknowledged the omission during an interview, and the Director of Subacute confirmed that this was a medication error and not in accordance with facility policy. Review of the facility's medication administration policy further supported the requirement to flush g-tubes with water between medications to ensure complete dosing and prevent complications.