High Medication Error Rate Due to Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 9 medication errors out of 25 opportunities, resulting in a 36% error rate. The deficiency involved one resident who had been admitted with diagnoses including lupus, acute respiratory failure, moderate protein-calorie malnutrition, gastrostomy status, and dysphagia. Physician orders for this resident in January 2026 included multiple medications scheduled for 9:00 A.M.: acidophilus 500 million units daily, Bactrim DS 800/160 mg daily, prednisone 10 mg daily, Protonix 40 mg DR daily, zinc sulfate 220 mg daily, Mucinex 600 mg twice daily, senna plus 8.6/50 mg twice daily, baclofen 10 mg three times daily, and oxycodone 10 mg three times daily. The orders specified that medications were to be administered via PEG tube, but there was no order for the medications to be mixed together and given as a cocktail. During observation, an LPN prepared the resident’s 9:00 A.M. medications by crushing one capsule of acidophilus and tablets of Bactrim DS, prednisone, Protonix, zinc sulfate, Mucinex, senna plus, baclofen, and oxycodone, then combining all the crushed medications into a single medication cup. The LPN mixed the powdered medications together and prepared to administer them via the resident’s PEG tube. At that time, the LPN verified that the resident was to receive all medications via PEG tube but acknowledged there was no order to cocktail the medications and administer them all at once. Review of the facility’s policy, “Administering Medication through an Enteral Tube,” dated 03/2015, showed that medications were not to be mixed together prior to administration through an enteral tube unless there was a physician’s order with a rationale, and that each medication should be administered separately unless otherwise ordered. The observed practice was inconsistent with both the physician’s orders and the facility’s policy, contributing to the identified medication error rate.
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