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Based on observation, record review and staff interview, the facility failed to ensure that drugs were administered according to physician's orders for 1 of 2 sampled patients, Patient #9.


The findings include:


On 12/11/2017 at 2:45 p.m., a medication observation was made with Employee A, a Registered Nurse for Patient #9. Employee A removed the 20 milliequivalent (MEQ) Potassium Chloride (KCL) medication from the dispenser and brought it to the patient's room. It was in powder form and the nurse mixed it in 120 cubic centimetres (CC) of water. The nurse stopped the patient's feeding (Osmolite continuous at 20 cc/hr) that was infusing through an orogastric tube (OGT). The nurse disconnected the tubing and checked placement by inserting 20 cc's of air into a syringe and pushing it through the OGT and listening with stethoscope to the abdomen at the same time. The nurse confirmed placement of the OGT. He did not check for residual at this time or flush the tubing with any water. He then removed the plunger from the syringe and poured about half of KCL mixture in the OGT tubing and allowed it to infuse by gravity. Then he poured in the remaining amount of mixture. He did not flush the tubing after the medication was finished.


On 12/11/2017 at 2:55 p.m., Employee A was interviewed. He confirmed he only checked for placement before administering the KCL through the OGT. He stated he did not check for residual at this time, because he checked it around noon. He confirmed he did not flush with water before or after medication administration. He stated he did not have to flush it with every medication administration.


Record Review for Patient #9 revealed on 12/4/2017 at 05:40 physician's order for KCL sliding scale, for a level between 3.5-3.7, give 20 meq. The Patient did have a KCL level of 3.7 on 12/11/2017 at 02:00.


Record review revealed a physician's order on 12/4/2017 at 9:26 a.m. for Orogastric tube, check gastric residual prior to gravity feeding and record. Flush with 50 cc's water before/after meds via PEG or NGT.


The facility's 8/2015 Nursing Tube Feedings (enteral Feedings), 7.12 Special Precautions revealed " Flush tube with 30 ML water if continuous flow is interrupted, for transfers, after meds, etc".


The Floor Manager for Patient #9 was interviewed on 12/12/2017 at 3:30 p.m. She stated she could not find a specific facility policy for the OGT, but it would have the same flush orders as an NG or PEG tubes. The physician's order on 12/4/2017 also should have included the OGT, not just the PEG or NGT tube.