BUTLER, GA- TAYLOR COUNTY HEALTH AND REHABILITATION

Based on observation, record review, staff interview, and review of facility policy titled, Medication
Administration – General and Enteral Tube Medication Administration, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 28 medication opportunities were observed, and there were six errors for one of five residents (R) (R #5), for an error rate of 21.43%.

Findings include:
Review of the facility policy titled Medication Administration – General dated 2019 revealed the intent of the policy is to ensure medications are administered as prescribed, in accordance with good nursing principle. Medications are administered in accordance with a valid prescriber order.

Prior to medication administration: the nurse should read the administration directions on the MAR (medication administration record) and verify correct medication, dose, and directions for use.

Review of the facility policy titled Enteral Tube Medication Administration dated 2019 revealed 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.

On 1/28/2023 at 8:15 a.m., Licensed Practical Nurse (LPN) CC was observed giving R#5 their 9 a.m. medications which included Baclofen 10 milligrams (mg) 1 tab (tablet), amlodipine 10 mg 1 tab, carvedilol 25 mg 1 tab, famotidine 20 mg 1 tab, and Eliquis 5 mg 1 tab given via gastrostomy tube (g-tube). LPN CC crushed each medication separately and then combined in a cup. LPN CC also prepared Lactulose 30 milliliters (ml) (10 gram/15 ml) and combined in the same cup. Further observation revealed LPN CC disconnected the g-tube from the water flush, poured the mixture of medications in the tube, then reconnected the water flush.

Record review of R#5’s January 2023 Physician Orders revealed the following orders:

Baclofen 10 mg 1 tablet g-tube every 4 hours; amlodipine 10 mg 1 tablet g-tube one time per day; carvedilol 25 mg 1 tablet g-tube two times per day; famotidine 20 mg 1 tablet g-tube two times per day; Eliquis 5 mg 1 tablet g-tube two times per day (DO NOT CRUSH, MAY DISSOLVE IN 60 ML OF WATER); and lactulose 10 gram/ 15 ml 30 grams g-tube one time per day.

LPN CC failed to administer the crushed medications separately, failed to administer the correct dose of lactulose, and failed to follow the instructions for dissolving the Eliquis in water.

Interview on 1/28/2023 at 8:45 a.m. with LPN CC, revealed she is an agency nurse. She stated she does not receive education through the facility but through her agency. She revealed the facility does have them sign off on policies. She stated she has always crushed the medications separately but administers them all together as one through the g-tube.

Interview on 1/29/2023 at 11:40 a.m. with the Director of Nursing (DON), revealed the nurse administering the medications is responsible for giving the medications appropriately and verifying the physician orders.