Failure to Administer Medications as Ordered Due to Inaccessible G-Tube
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for medication administration for a resident with multiple complex medical conditions, including COPD, anxiety, depression, stroke with right-sided hemiplegia, aphasia, and dysphagia. The resident required significant assistance with daily activities and received more than half of their caloric intake via a feeding tube. The physician's order specified that medications could be crushed and administered through the feeding tube every shift. However, on one occasion, the resident did not receive seven scheduled evening medications because the nurse was unable to access the G-tube. The nurse documented the missed medications and stated that he did not believe missing the nighttime medications would be detrimental. The resident later confirmed not receiving the medications. The DON indicated that staff should have contacted the on-call nurse and escalated the issue if necessary. Additionally, the facility administrator acknowledged that there was no policy in place regarding adherence to physician's orders.