Failure to Follow Medication Administration Protocols for G-Tube Resident
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a resident with Myasthenia Gravis and a G-tube according to physician orders. The resident, who was tube-fed and not to receive anything by mouth, was found sitting in the hallway with her feeding tube disconnected. The nurse did not verify the resident's identity or the correct route of administration, crushed the medications, mixed them with applesauce, and gave them orally. This resulted in the resident choking and requiring suctioning and emergency services. Record review confirmed that the resident's medication orders specified administration via G-tube, with no recent changes to these orders. Facility policy required verification of resident identity and the five rights of medication administration, which were not followed in this incident. The nurse's last observed medication pass was several months prior, and the DON confirmed multiple failures in following medication administration protocols.