Medication Administration Errors via Gastrostomy Tube
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a gastrostomy tube, resulting in a medication error rate of 48% (12 errors out of 25 opportunities) during medication administration. The resident, who had diagnoses including dysphagia, nontraumatic intracranial hemorrhage, congestive heart failure, gastrostomy, and dementia, was observed receiving multiple medications crushed and administered via a gastrostomy tube by an LPN. There was no physician order to administer these medications through the enteral tube, and the medications were ordered to be given orally, with instructions that they could be crushed and given with food if appropriate. During the observed medication pass, the LPN did not check the gastrostomy tube for placement or flush it prior to administration, and only flushed the tube after administering the medications. The LPN confirmed that all medications, including those not intended for enteral administration, were crushed and given via the tube without a proper order. Facility policy required verification of a physician's order for enteral tube medication administration and adherence to the prescribed route, which was not followed in this instance.