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CLEVELAND CLINIC
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on medical record review, policy review, and interview, the facility failed to ensure drugs were prepared and administered in accordance with accepted standards of practice for one of 10 patients reviewed (Patient #2). The facility's census was 1083.
Findings include:
Review of the facility's policy titled, The facility's Enteral Tubes for Feeding, Medication Administration: Care of the Adult Patient with Protocol (Version 5, Effective Date 05/11/22), revealed to prepare medications for administration via feeding tube, verify which medication may be crushed with Pharmacy Formulary Guidelines. Pharmaceutical products which are controlled release (CR), long acting (LA), sustained release (SR), time released (TR), sustained (SA), enteric coated (EC) or extended release (XR, XL, CD) are not administered via an enteral feeding tube. Alternatives are discussed with Pharmacy and physician/LIP prior to administering the medication to the patient. Notify Pharmacy and physician/LIP of the need to supply liquid medications rather than pills when applicable. Crush and administer each medication separately. Do not crush hazardous medications. Flush tube with 15 milliliters ml - 30 ml of water before, between and after each medication administration. Use oral dispensers (amber syringes) to administer oral liquid medications, including medications crushed and added to liquid for administration. A larger syringe (ex. Toomey or Davol) may also be used. Do not use injectable syringes to administer oral liquid medications.
Per medical record review, Staff L administered Patient #2's multiple medications via a feeding tube on 09/15/23 at 9:14 PM.
Staff L was interviewed on 11/14/23 at 8:25 AM. Staff L reported she crushed individual patient medications separately but administered all of a patient's crushed medications mixed together, at the same time.
The findings were shared with Staff G in an interview on 11/14/23 at 8:32 AM and confirmed.
This deficiency represents non-compliance investigated under Substantial Allegation OH00146762.