Incomplete Administration of G-Tube Medications Due to Improper Mixing
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to ensure the complete administration of two prescribed medications, glycopyrrolate and ascorbic acid (Vitamin C), to a resident with a G-tube. The LVN prepared the medications by adding water to the medication cups but did not stir or ensure the medications were fully dissolved before administration. After administering the medications via the resident's G-tube, a white pasty residue was observed remaining in the cups, indicating that not all of the medication had been delivered to the resident. The resident involved had a history of respiratory failure, a tracheostomy, and was dependent on a G-tube for feeding due to swallowing difficulties. The resident was assessed as having severely impaired cognitive skills and required maximal assistance with daily activities. Physician orders were in place for the administration of glycopyrrolate and Vitamin C via the feeding tube, with specific dosages and frequencies. During interviews, the LVN acknowledged that the medications were not completely dissolved and that the resident did not receive the full prescribed doses. The Director of Nursing (DON) confirmed that facility policy required medications to be mixed and fully dissolved before administration, and that no residue should remain in the medication cups. The failure to follow these procedures resulted in the resident not receiving the entire dose of the prescribed medications.