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Based on interview, and record review, the facility failed to ensure documentation of medication administration route was accurately entered into the patient electronic health record (EHR) for 1 of 10 patients reviewed for medication reconciliation administration of home medications, out of a total sample of 10 patients, (#8).


Findings:

The electronic medical record (EHR) showed patient #8 was admitted in the emergency room on 5/22/24, with diagnoses of dementia, congestive heart failure, seizures, and gastrostomy tube (Peg tube).

Review of the nutritional consult note dated 5/23/24 at 4:12 PM, showed Registered Nurse (RN) reported patient #8's son stated patient does not eat by mouth (PO).

Physician diet order dated 05/23/24 revealed diet nothing by mouth (NPO) except tube feed (TF).

Review of pharmacy report for administration of medications showed Zyvox 600 mg tablet ordered orally every 12 hours and documented by nurses as administered orally on 05/23/24 at 12:54 PM, 05/23/24 at 8:17 PM, 05/24/24 at 8:35 PM, 05/25/24 at 10:04 AM, 05/25/24 at 8:22 PM, 05/26/24 at 8:46 AM, 05/26/24 at 9:48 PM, 05/27/24 at 10:24 AM, and 05/27/24 at 8:04 PM. On 05/27/24 at 7:34 PM, Levetiracetam (Keppra) 500 mg tablet, a one time dose was also documented as given orally. The report reflected a total of 10 doses of oral medication documented as administered by nursing to patient #8 over a 5-day timeframe.

On 08/27/24 at 2:46 PM, Nurse Manager (A), and Director of Nursing (B), both confirmed nursing documentation reflects medications were given orally to patient #8. Nurse Manager (A) stated patient is NPO except for TF and no sips of H20 or ice chips were ordered by the physician.

On 08/28/24 at 12:32 PM, Nurse Professional Development (NPD) Practitioner stated computer displays the administration route to nursing, and it is automatically processed by the placement of the physician order. If the route does not match, the expectation and hospital process for a peg tube is that nurses follow the five rights for medication administration (right patient, right drug, right dose, right time, and right route). She stated the physician's order should reflect the correct route and if it does not, the nurse needs to reach out and contact the physician to clarify the orders.

On 08/28/24 at 12:59 PM, Nurse Manager (A), stated she spoke with 6 out of the 8 nurses and confirmed they all administered the medication through the peg tube as the patient was not be able to swallow oral medications. She, too, stated the hospital policy is for nursing to call and have the physician order clarified for the right route. They can either contact the physician or the pharmacy, whomever placed the order.

Review of hospital policy SOP# CFD.MM.SOP.33 for Medication Administration with an effective date 4/3/24, showed under the heading for process and procedures that medications will be administered to the patient only upon the order of the physician and the medications will be administered by oral route if the patient is able to take PO.

The hospital did not ensure accuracy of medication administration documentation in the medical record for patient #8.