Medication Error Rate Exceeds 5% Due to Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 25 opportunities, resulting in a 20% error rate. The deficiency involved a resident with dysphagia and a PEG tube, who had physician orders specifying that the tube should be flushed with water before and after each individual medication. During a medication pass, an agency nurse prepared and administered all of the resident's prescribed tablets together, crushing them and mixing them in water, rather than administering each medication separately with the required water flushes between each one. The nurse was unaware of the specific physician orders requiring individual administration and separate flushes, and there were no orders permitting the medications to be combined. The Director of Nursing confirmed that staff are expected to follow all medication administration orders. These actions led to the facility exceeding the acceptable medication error rate and not adhering to the resident's prescribed medication administration protocol.