HospitalInspections.org

Based on observations, interviews and record reviews, the facility failed to provide adequate medication administration through a Gastrostomy Tube (G-Tube) for 3 (#6, #7 #8) of 3 patients observed for Medication Pass.

The findings include:

1. During medication pass observation on 1/21/16 at 8:49 AM for Patient #6, Employee D was instructed that she would be observed for medication pass. Employee D was wearing a pair of gloves. She went over to her computer located in the patient's room. She touched the computer screen with her gloved hands. She then stated she needed to get a syringe and walked out of the patient's room to the medication cart in the hallway. She opened the medication drawer with her gloved hands, returned to the room and touched the computer screen with her gloved hands. She drew up Novolin R 1 unit in the syringe, walked over to Patient #6 and injected her right upper arm with the insulin. Employee #6 proceeded to draw up Levemir 5 units in a syringe. She was informed that she contaminated her gloves by touching the computer two times, as well as the medication cart, and needed to sanitize her hands. Employee D donned new gloves. Employee D sanitized her hands, donned new gloves and correctly injected Levemir 5 units in the right upper arm.



Employee D prepared to administer the balance of the patient's medications. She prepared 3 cups of water in separate cups to dilute the medications. Patient #6 was to receive Guaifenesin 200 mg/10cc with 30 cc of water, liquid protein 74 cc, Risa bid 1 tablet crushed mixed in 30 cc of water and Protonix 40mg delayed release granules in 30 cc water. Employee D failed to prep the patient with a towel for any spills. She checked placement of the Gastrostomy Tube by auscultating bowel sounds with her stethoscope and she attempted to withdraw stomach contents. She attached the syringe to the G-Tube without the piston to allow the medications to flow by gravity initially, and then she placed the plunger into the syringe and pushed the medications through the tube. She picked up the Liquid Protein 74 cc, and used the plunger to push it through the G-Tube. She did not indicate that there was a problem. Protonix 40mg delayed release granules in 30 cc water was also pushed through the G-Tube using the plunger. The Staff Nurse never flushed the G-Tube with water between each medication.

Interview with Employee D on 1/21/16 at 9:14 am revealed she did not think about flushing the tube after every medication. When asked about the towel to cover the patient, she stated there was one in there. She returned to the patient's bedside and the towel was bunched up under the patient.

Interview with the Chief Operating Officer (COO) on 1/21/16 at 1:39 pm revealed staff education was done in 2015 for Administration of Gastrostomy Tubes; that they did 10 audits per week for 3 months in 2015. The COO stated that after 3 months, people were adhering to administering the drugs by gravity.

Review of Education and Training dated 8/12/15 revealed that all medications given via PEG Tube must be crushed individually, placed in individual cups and given via gravity. Never pushed into the PEG.

Review of the Policy and Procedures for Administration of Medications dated 5/2015 revealed that staff should flush between medications with 15 ml of water when they have to administer more than 1 medication via a feeding tube.


2. Observation of medication administration on 1/22/16 at 8:27 AM for Patient #8 revealed Registered Nurse, RN (Employee A) crushed Aspirin 325mg, placed it in a cup and mixed with 20ml of water. He then administered by pushing the medication into the PEG feeding tube. He then gave all the other medications crushed individually, placed in individual cups and given via gravity.

Brief interview on 1/22/16 at 8:45AM with Registered Nurse, RN (Employee A) regarding Patient #8's administration of Aspirin, revealed that he failed to give the aspirin by gravity.

Review of Education Attendance Roster, Kindred Healthcare FL with program title Huddle PEG on 8/5/15, indicates Employee A attended this training program. The training program included, "All medications given via PEG must be crushed individually, placed in individual cups, and given via gravity. Never pushed into the PEG."


3. Observation of medication administration for Patient #7 on 1/22/16 at 9:20 AM, Registered Nurse, RN (Employee B) crushed 4 of the 7 medications ordered (Protonix 40mg crushed, Vitamin C 500mg crushed, Vitamin B12 250mcg crushed, Colace Liquid 10mg, Levetiracetam Liquid 100mg, Multivitamin 15ml, Zinc sulfate 220mg) individually, placed it in a cup individually and mixed each medication with 20ml of water individually. She then administered each medication one by one, by allowing the medication into the PEG feeding tube to flow by gravity without flushing between medications with 15ml of water.

Brief interview on 1/22/16 at 9:45AM with Registered Nurse, RN (Employee B) regarding Patient #7, when asked about flushing between medications with water, she indicated that she now recognized that she failed to flush between medications with water for Patient #7. She stated she got nervous.

A review of the facility's Medication Administration policy, May 2015 revealed, "Medications via feeding tube. To administer more than one medication, give each separately and flush between medications with 15ml of water."