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F0658
D

Incorrect Transcription of Medication Administration Route for G-Tube Resident

Wadesboro, North Carolina Survey Completed on 05-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medication administration routes were accurately transcribed for a resident with a gastric feeding tube. The resident, who had diagnoses including cerebrovascular disease and dysphagia, was assessed as having severely impaired cognition and was receiving all nutrition and fluids via a feeding tube. Despite having physician orders indicating the resident was NPO and required medications to be administered through the gastric tube, several medications were entered into the Electronic Medical Record (EMR) with the default route as oral. Specifically, orders for Briviact, Hydrocodone-Acetaminophen, and Lacosamide were transcribed with the oral route instead of via G-tube. Interviews with nursing staff revealed that the EMR system defaulted to the oral route, and staff failed to update the route to reflect the resident's need for G-tube administration. The nurses involved acknowledged the oversight, and the DON confirmed that the medication orders were incorrectly entered as oral. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive any medications orally, but the orders in the EMR did not accurately reflect the required administration route.

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