Crushed Medications Improperly Combined for G-Tube Administration, Exceeding Acceptable Med Error Rate
Penalty
Summary
Surveyors identified a deficiency in medication administration when staff failed to maintain a medication error rate below 5%, documenting four errors out of 32 opportunities (12.5%) during medication administration observations. During one observation of medication administration via feeding tube for Resident #106, an LVN prepared four different medications by crushing or pouring them from capsules and combined all four into a single medication cup before administration. Record review showed physician orders for Eliquis 5 mg via G-tube, Ferrous Sulfate 325 mg via G-tube, Pantoprazole Sodium delayed-release tablet via G-tube, and Tylenol 325 mg, two tablets via G-tube every six hours as needed for pain. The facility’s policy dated 04/12/23 stated that crushed medications are not to be mixed into the same medicine cup unless approved by the prescribing physician. In an interview, the DON stated that medications should be prepared in separate medicine cups before administering them through a feeding tube and confirmed that combining crushed medications into one cup did not meet her expectations. This deficient practice resulted in a calculated medication error rate of 12.5%, exceeding the regulatory threshold of 5% for medication errors during the survey review of six residents receiving medication administration.
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