GLENDALE, AZ- HORIZON POST ACUTE AND REHABILITATION CENTER

Based on observations, clinical record reviews, staff interviews, review of facility documents, and review of policies and procedures, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to two residents (#27 and #183). The error rate was 10.71%. The deficient practice could result in further medication errors.

Findings include:
-Resident #183 was most recently admitted to the facility on [DATE] with diagnoses that included cutaneous abscess of the abdominal wall, severe protein-calorie malnutrition, and gastrostomy status.

On March 30, 2022 at 8:14 a.m., a Licensed Practical Nurse (LPN/ staff #143) was observed to administer resident #183 medications during a medication administration observation. The LPN was observed to separately crush four medications, including a Carafate tablet, and mix the medications with water in separate medication cups. The LPN put the resident’s tube feeding on hold; flushed the gastrostomy tube with water; and administered the medications separately through the gastrostomy tube with a water flush between each medication.

However, review of the physician’s orders revealed an Enteral Feeding Order dated March 12, 2022, every shift may crush medications and administer via feeding tube unless contraindicated; and an order dated March 21, 2022 for Sucralfate (Carafate) 1 gram (GM) tablet by mouth three times a day for gastric
protection.

An interview was conducted on March 30, 2022 at 12:51 p.m. with the LPN (#143). He stated that he was expected to follow the route of medication administration that was written in the physician’s order. He stated that he would contact the physician and clarify the order if he thought the order was wrong. The LPN reviewed the order and stated that the order was to give the Carafate by mouth. He stated that he had crushed and given the medication by gastrostomy tube and that it was an error. He stated that if he had noticed that the medication was ordered to be given by mouth he would have called the physician and gotten the order clarified as the resident could eat food by mouth. 

Review of facility provided documentation of undated PDR.net (Physician Desk Reference) drug information for Carafate revealed: Oral administration, Take on an empty stomach at least one hour prior to a meal and at bedtime. Oral Solid Formulations: Tablets; Do not crush or chew (the tablet dosage form is not amenable to crushing or chewing).

-Resident #27 was admitted to the facility on [DATE] with diagnoses that included sepsis, muscle weakness, and dysphagia.

On March 30, 2022, starting at 8:43 a.m., an LPN (staff #86) was observed to administer three resident’s medications, including resident #27, during a medication administration observation. During the observations, the LPN was observed to administer resident #27 medications that included aspirin and Baclofen (skeletal muscle relaxant). The nurse crushed and combined the medications being administered and mixed the medications into applesauce.

Review of the physician’s orders revealed an order dated February 11, 2019 for aspirin tablet 81 milligram (mg) tablet by mouth one time a day for Deep Vein Thrombosis (DVT) prophylaxis; and an order dated March 24, 2021 for Baclofen 5 mg tablet by mouth one time a day for muscle contractures.

However, review of the clinical record did not reveal orders, or other documentation, that the resident was to receive medications in crushed form or to combine the crushed medications.
An interview was conducted on March 30, 2022 at 12:26 p.m. with the resident. She stated that she is able to take her medication whole and that she had not requested her medications to be crushed, she further stated that she did not care either way.

An interview was conducted on March 30, 2022 at 12:29 p.m. with the LPN (staff #86). She stated that the resident had had difficulty with taking whole pills because the resident had only one or two teeth. She stated the resident’s medication administration had been changed to crushing the medications and mixing them in applesauce, or giving whole in applesauce. The LPN stated that the resident should have an order to crush the medication and to combine the medications. The nurse reviewed the physician’s orders for the resident and stated that there was no order to crush the resident’s medications. She stated that she should not have crushed the medications without an order. The LPN stated that she did not follow protocol and there would be risks to the resident of crushing a medication that was contraindicated for crushing, or a risk of
interactions between the medications that were mixed together.

An interview was conducted on March 30, 2022 at 1:49 p.m. with the DON (staff #142). She stated that a resident may have an order to crush and combine medications unless contraindicated. She stated that the order should be in the electronic record as an order. The DON stated that if the resident did not have the order to crush and combine their medications then staff would not be able to crush the resident’s medications. The DON stated the risk of crushing a resident’s medications without a physician’s order would be that staff might crush a medication that was contraindicated for crushing and/or the medications could contradict one another if mixed. She stated that the resident’s medications may not have been reviewed by the pharmacist to determine if the medications could be crushed.

Review of a policy for Administration of Drugs revised May 2021 included it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. Right route-medications are administered according to the route prescribed.