Medication Error Rate Exceeds 5% Due to Improper PEG-Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 27 opportunities, resulting in an 18.52% error rate. The deficiency involved a resident with a percutaneous endoscopic gastrostomy (PEG) tube, who had specific physician orders for medication administration. The orders required each medication to be dissolved separately in water, administered individually, and flushed with water between each medication, with a final flush at the end. During observation, the Unit Manager combined all prescribed medications into a single mixture, crushed and mixed them together, and administered them as a single solution through the PEG tube, contrary to the physician's orders. The Unit Manager admitted to not reviewing the resident's medication administration order prior to administering the medications and stated that her usual practice was to combine all medications for PEG-tube administration. The Director of Nursing confirmed that staff are expected to follow all medication orders as written. The observed practice resulted in multiple medication errors for the resident, as the administration did not comply with the specific instructions provided by the physician.