Failure to Administer Enteral Medications per Physician Order
Penalty
Summary
A deficiency occurred when a nurse failed to administer enteral medications according to physician orders for a resident with a gastrostomy tube. The nurse combined multiple medications into a single cup and administered them as a cocktail, rather than crushing and administering each medication separately with warm water as specified in the physician's order and facility policy. The nurse also did not use warm water for flushing the tube, as required by the order. The resident involved was an elderly female with multiple medical diagnoses, including unspecified dementia, gastrostomy status, hypertension, anemia, and hydronephrosis. Her care plan and medication administration record indicated that medications should be administered as ordered by the physician, with specific instructions to flush the tube with 30cc of warm water before and after administration. There was no order permitting the mixing of medications for enteral administration. Interviews with other nursing staff, the DON, and review of facility policies confirmed that the standard practice is to crush and administer each medication separately, flushing the tube with warm water between medications, unless otherwise ordered by a physician. Staff consistently stated that medications should not be mixed due to the risk of adverse reactions and tube clogging. The nurse involved acknowledged awareness of the correct procedure but attributed the error to nervousness during observation by a state surveyor.