Missed G-tube Medications and False MAR Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration and documentation of multiple medications for one resident with significant medical needs. The resident was an elderly female with hemiplegia following a stroke, dementia with severe cognitive impairment (BIMS score of 2), depression, and gastrostomy status requiring tube feeding. Physician orders directed that she receive several medications via G-tube or orally, including atorvastatin for hyperlipidemia, cetirizine for allergic rhinitis, melatonin for sleep, ropinirole for restless legs syndrome, venlafaxine for depression, Depakene for migraines related to cerebral infarction, gabapentin for neuropathy, and biotin for buccal moisture. After a recent hospitalization and return with a feeding tube, her medications had been changed to G-tube administration, but the MAR still reflected these scheduled PM medications. On the night in question, there was confusion and miscommunication between two nurses regarding which medications had been administered. LVN D reported that she sometimes helped the night shift by giving only PO medications to some residents and left a written note listing specific rooms where she had given 8:00 PM medications; this list did not include the room of the resident in question. LVN D stated the resident did not have any PO medications and that it was possible RN C thought she had given the G-tube medications. CNA E, who worked the 10:00 PM to 6:00 AM shift, reported she did not specifically see RN C enter the resident’s room during that shift. Video clips from the resident’s room, which were motion-activated and not continuous, showed only a CNA entering the room around the start and near the end of the night; there was no visual evidence of either nurse entering to administer G-tube medications. RN C acknowledged that she did not administer the resident’s PM G-tube medications on that night. She stated she arrived at 10:00 PM, saw the note from LVN D, misread it, and believed that LVN D had already given the resident’s G-tube medications. Despite not administering the medications herself, RN C signed off on the MAR as though the PM doses of atorvastatin, cetirizine, melatonin, ropinirole, venlafaxine, Depakene, gabapentin, and biotin had been given. Facility staff, including other nurses and leadership, stated that checking off medications not personally administered is a medication error and contrary to nursing standards and facility policy, which requires medications to be administered as prescribed and documented by the person who actually gives them, following the rights of medication administration, including right documentation. The facility’s own Medication Administration and General Guidelines Policy specified that medications must be administered in accordance with physician orders and that the resident’s MAR is to be initialed by the person administering the medication, adhering to the rights of medication administration, including right documentation. In this case, the resident’s PM medications were not administered as ordered, and the MAR was inaccurately completed to indicate that they had been given. The facility’s internal review, including interviews with the RCN, ADM, NP, and other nursing staff, confirmed that the resident likely did not receive the ordered PM medications and that RN C documented their administration despite not providing them.
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