NEWNAN,GA-AVALON HEALTH AND REHABILITATION

Based on observation, record review, review of facility policy titled Enteral Tube Medication Administration, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 34 medication opportunities were observed, and there were three errors for one of four residents (R) (R #1) for an error rate of 8.82%.

Findings include:
Observation on 4/24/22 at 8:39 a.m. revealed Licensed Practical Nurse (LPN) AA prepared medications to administer to R#1 via gastrostomy tube (g-tube). The medications were cefuroxime 500 milligrams (mg), Vitamin C 500 mg, and Vitamin D3 10 micrograms (mcg). The three medications were crushed and combined into a medicine cup. LPN AA then added water to the cup and entered the resident’s room. She checked residual and poured the medication mixture into the syringe for the g-tube. She added water so that the medications would go down the tube. She then poured feeding into the syringe for the g-tube several
times also adding water so that the feeding would go down the tube. She did not appear to be measuring the water.

Interview with LPN AA immediately after medication administration revealed that it is the facility’s policy to crush g-tube medications and to mix them together without keeping them separate during administration. She stated she used the measurement lines on the syringe to flush the tube with 30 ml of water before the feeding, 30 ml of water after the feeding, and she gave 5 ml of water with the medications. She stated she always crushes the medications for the g-tube and administers them together at one time.

Interview with the Director of Nursing (DON) on 4/24/22 at 9:00 a.m. revealed that she believes the facility policy does not indicate to crush medications and administer separately for g-tube medications. Review of facility policy titled Enteral Tube Medication Administration dated 2019 revealed under guideline: it is recommended that crushed medications not be combined and given all at once via feeding tube in order to
avoid obstructing the tube and to ensure the complete delivery of each medication.

Review of the April 2022 Physician Orders for R#1 included the following orders: cefuroxime axetil 500 mg tablet per PEG Tube (g-tube) two times per day for seven days, feeding tube flush with 30 ml before meds, 5 ml between each med, 30 ml after all meds, vitamin C 500 mg tablet per feeding tube two times per day and vitamin D 1000 IU (25mcg) one tablet per feeding tube two times per day.

Interview and observation with LPN BB on 4/24/22 at 9:25 a.m. revealed the medication carts had the wrong bottle of vitamin D3 (the 10 mcg) but now have the right one, which is the 25 mcg tablet.