High Medication Error Rate and Improper GT Medication Administration with Missing MAR Documentation
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5 percent, with surveyors identifying a 24 percent error rate based on 25 medication observations. During a medication pass, an LPN administered medications via a gastrostomy tube (GT) to a resident by crushing multiple medications together in one envelope, mixing them in water, and giving them through the GT, contrary to professional standards that require medications to be crushed and administered separately. In the same observation, a scheduled dose of Coreg 6.25 mg was omitted because it was not available on the medication cart, and the LPN did not contact the pharmacy or check emergency stock for the medication. The LPN later stated she had limited experience with GT medication administration, had been informally shown the process by another LPN, and was unaware of the proper method and potential harm of the practice. In addition, review of the electronic medical record and MARs revealed multiple instances of missing medication administration documentation for three residents on specific dates. For one resident, there was missing documentation for enoxaparin, diazepam, Micatin cream, albuterol inhalation solution, and oxycodone at various scheduled times. For another resident with a GT, there were missing entries for blood pressure checks and administration of amlodipine, Coreg, clonidine patch, MiraLax, Nexium, vitamin B1, amantadine, enteral feedings, and a change of feeding syringe on the night shift. A third resident’s MAR showed missing documentation for Protonix, methocarbamol, acetaminophen, and oxycodone at scheduled early morning times. The DON confirmed that mixing crushed medications for GT administration was a deficient practice and acknowledged the missing MAR documentation for the three residents, and the Administrator stated that medications should be given per policy and professional standards.
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