Medication Administered by Incorrect Route
Penalty
Summary
A deficiency occurred when a licensed nurse administered an anti-seizure medication, levetiracetam oral solution, by mouth to a resident who had a physician's order specifying administration via PEG tube. The resident, who had a history of intracranial injury, gastrostomy, and post-traumatic seizures, was observed taking the medication orally despite the order indicating the PEG tube route. The nurse explained that the resident had transitioned to oral intake following a swallow study, but the PEG tube remained in place pending reassessment for removal. However, the medication order had not been updated to reflect this change in administration route. Interviews with nursing staff and the Director of Nursing confirmed that any changes to medication administration routes should be documented in the electronic health record and communicated to the nursing staff. The facility's policy and standard nursing procedures require medications to be administered as prescribed, including the correct route. The failure to update the physician's order and administer the medication as ordered resulted in a medication error for the resident.