Failure to Accurately Document and Administer Medications for NPO Resident with Gastrostomy Tube
Penalty
Summary
A physician failed to accurately document medication orders for a resident with a gastrostomy tube (GT) who was readmitted to the facility with an NPO (nothing by mouth) order. Despite the resident's NPO status and the presence of a GT for medication and nutrition administration, the physician's orders specified that medications such as Tylenol and Tramadol be given orally. This order was not clarified by nursing staff, and the medications were subsequently documented and administered by mouth according to the Medication Administration Record (MAR). Record reviews showed that over several days, the resident received multiple doses of Tylenol and Tramadol by mouth, as indicated on the MAR, even though the resident was not to receive anything orally due to the NPO order. Both the Registered Nurse Supervisor (RNS) and Assistant Director of Nursing (ADON) confirmed during interviews that the medications were given by mouth and acknowledged that this was inconsistent with the resident's NPO status and the correct route for administration via GT. The facility's policy on the six rights of medication administration requires that medications be given according to the prescribed route, and that orders be checked for accuracy before administration. In this case, the nursing staff did not clarify the conflicting orders with the physician or pharmacy, and the medications were administered and documented incorrectly, resulting in a failure to follow accepted professional standards for safeguarding resident care and accurate medical recordkeeping.