Failure to Follow Physician Orders for Feeding Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a PEG/feeding tube, admitted with a history of traumatic brain injury and NPO status, did not receive care in accordance with physician orders during medication administration. The resident's care plan included tube feeding and specific flushes as ordered by the physician, which required flushing the feeding tube with 5 ml of water between each medication and 30 ml of water before and after each medication. During a medication pass observation, an LPN crushed eight medications and mixed them together with water, administering them all at once through the feeding tube, followed by a single flush of 30 ml of water before and after the administration. The LPN confirmed in an interview that she did not flush 5 ml of water between each medication as ordered, instead administering all medications together and only flushing before and after. This failure to follow the physician's specific orders for medication administration via feeding tube constituted the deficiency.