Failure to Clarify Medication Route for NPO Resident
Penalty
Summary
A deficiency occurred when a nurse administered Quetiapine, ordered to be given by mouth, via a gastrostomy tube (G-tube) to a resident who was documented as NPO (nothing by mouth) and receiving all medications through a G-tube. The nurse did not clarify the route of administration with the physician before giving the medication through the G-tube, despite the order specifying oral administration. The facility's policy required verification of physician orders for medication and enteral tube flush amounts, but this step was not followed for the Quetiapine order. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living and mobility, and had multiple diagnoses including encephalopathy, diabetes mellitus, and dysphagia. The medication administration was observed by surveyors, and both the nurse and the Director of Nursing acknowledged during interviews that not all oral medications are safe to administer via G-tube without physician clarification, as this could affect medication safety and effectiveness. The failure to clarify the medication route resulted in a significant medication error.