Medication Error Rate Exceeds 5% Due to Improper Administration via PEG Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as three errors were identified out of 32 opportunities, resulting in a 9.38% error rate. This deficiency involved a resident with a history of gastrostomy status, hypertension, and peripheral vascular disease, who had physician orders for multiple medications to be administered via PEG tube. The orders specified that Losartan Potassium should be held if the resident's systolic blood pressure was less than 105, and that each medication should be administered separately with a 5 ml water flush between each, as well as a 60 ml flush before and after all medications. During observation, an RN prepared all scheduled medications for the resident by crushing and combining them in a single cup, then administered them together without separating them or flushing the tube with 5 ml of water between each medication. The RN also failed to check the resident's blood pressure prior to administering Losartan Potassium, as required by the physician's order. The RN confirmed during interview that the medications were given all at once, the required water flushes between medications were omitted, and vital signs had not been taken prior to administration. Review of facility policy confirmed that medications should be given separately with appropriate flushing between each.