Failure to Administer Medications as Ordered via G-Tube
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to accurately administer medications to a resident with a history of cerebrovascular accident, hemiplegia, muscle weakness, and cognitive confusion, who required assistance for activities of daily living and received medications via G-tube. The RN did not follow physician orders for three separate medications during a medication pass. Specifically, the RN administered a chewable aspirin (ASA) 81 mg via G-tube instead of the ordered ASA 81 mg capsule, without checking the medication room or consulting other staff for the correct form of the medication. Additionally, the RN administered an over-the-counter Calcium D supplement instead of the prescribed Calcium D oral tablet 600-400 mg, and did not mix the medication properly before administering it through the G-tube. The RN also failed to administer the ordered Maalox (aluminum/magnesium suspension) and instead gave Geritol 5 ml. These actions were observed during the medication pass, and the RN acknowledged not following the correct procedures, citing being busy and running behind as reasons for the errors. Interviews with the RN and the Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered as prescribed and that staff should notify the DON if medications are unavailable. The RN admitted to not following the established medication administration process, including verifying medication availability and consulting with the DON or physician before substituting medications.