Failure to Administer Medications via PEG Tube and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with a PEG tube and a history of dysphagia, cerebral ischemia, and recurrent aspiration was observed self-administering whole pills orally without staff supervision. The resident was seen walking out of his room holding a medication cup with several whole pills, dropping one on the floor, picking it up, and then returning to his room to swallow the pills. The resident's medical record indicated that all prescribed medications were ordered to be administered via PEG tube, and there was no assessment, care plan, or physician order permitting self-administration of medications by mouth. Interviews with staff, including an LPN and the SLP, confirmed that the resident was at high risk for aspiration and that medications should have been given via PEG tube as ordered. The SLP noted that the resident coughed when attempting to swallow pills and was at risk for silent aspiration. The facility's policy required verification of physician orders and monitoring for aspiration during tube feeding, but these procedures were not followed in this instance, resulting in the resident receiving medications by an incorrect route and without adequate supervision.