Medication Error Rate Exceeds 5% Due to Improper Administration via Gastric Tube
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent, as evidenced by an 11% error rate (5 errors out of 44 opportunities) during medication administration for one resident. Specifically, a registered nurse (RN) combined five different medications and administered them together via a gastric tube, rather than administering each medication separately with a water flush between each, as ordered by the physician and outlined in facility policy. This practice was observed during a morning medication pass, and the resident confirmed that medications were always given in this manner. The resident involved was a male with a history of stroke, cognitive impairment, and required a gastric tube for all nutrition and medication administration. Physician orders and the facility's policy required each medication to be prepared and administered separately, with water flushes before and between each medication to prevent tube clogging. The RN admitted to combining medications to save time during busy shifts, despite knowing this was not the correct procedure. The DON confirmed that the RN had not yet been checked off on proper gastric tube medication administration.