HospitalInspections.org

Based on observations, staff interviews and record review, the facility failed to administer medications through a Gastrostomy (stomach) tube (G-Tube), using Standards of Practice for 1 (#2) of 3 sampled patients.


The findings include:

On 4/23/15 at 9:34 am, Employee A, Staff RN, entered the patient's room (Patient #2) to administer 7 medications through the patient's G-Tube. Employee A washed her hands and donned a new pair of gloves. She placed the medications on the patient's bedside table and went to the foot of the bed to raise up the bed, and turned off the bed alarm with her glove hands. Employee A stated the bed alarm would go off during Medication Pass if not turned off. Employee A identified the patient and explained each medication to the patient. She crushed the first medication, Doxycline (antibiotic) and placed it in a denture cup that was pre-labelled for the patient. She withdrew the medication from the denture cup with the piston syringe and directly injected the medication into the G-tube without allowing the medication to flow by gravity.

The second medication given was Levetiracetam (Keppra) 500 mg for seizures. Employee A crushed the pill using the pill crusher. She placed the crushed pill into the plastic denture cup. Employee A added water to the crushed pill and used her gloved finger that touched the bed to dilute the solution. She removed the crushed medication that stuck to the pill crusher with her finger and placed the balance of crushed medication into the denture cup. She withdrew the medication from the denture cup with the piston syringe while continuing to mix the solution; She stated that it was a bit clumpy. The medication was poured into the piston syringe and it flowed by gravity. The nurse stated to the patient, "You are getting potassium next." The piston syringe was attached to the G-Tube. Employee A leaned the syringe up against the siderail near the triangular space to hold it in place while she prepared the next medication. After administering potassium by gravity, the nurse placed the syringe that was still attached to the G-Tube up against the siderail again, when she turned her back to prepare the next medication.

The next two medications (Carvedilol 12.5 mg for B/P and Prednisone 20 mg for inflammation) were given using the same technique. The syringe and G-Tube were left attached. The nurse leaned the syringe against the siderail while she prepared the last medication. When the nurse prepared the last medication, Lisinopril (B/P medication), she added water to the denture cup and stirred the mixture with her glove hand. The medication was poured into the piston syringe and was allowed to flow by gravity.

Interview with Employee A, Staff RN, on 4/23/15 at 10:12 am revealed she used denture cups to mix medications. She stated that she labelled the cup with the patient's name and that she found it easier to use denture cups. Employee A stated that she crushes the medication, places it in the denture cup, pours water and mixes. The staff nurse did not see anything wrong with using her finger to mix the medication. She stated that it was a clean procedure. Employee A did not realize that she touched many surfaces such as the bed, bed controls and bedside table in the patient's room. She did not mention that she should use a spoon to mix the medications. She stated the pill crusher was still wet and made the medication clumpy and she liked the medication to be completely dissolved so it would not clog up the tube.


On 4/23/15 at 10:55am, the Infection Control Officer was interviewed. She stated that the procedure the nurse used was not standard practice and that it was an opportunity to re-educate.

Review of the policy and procedure for Medication Administration did not reveal any directives or guidelines on how to administer medications through a G-tube for staff to follow. There were no resources found on the facility's intranet regarding G-Tubes by the Infection Control officer for staff to use.