| 48 |
WEISER CARE OF CASCADIA |
135010 |
331 EAST PARK STREET |
WEISER |
ID |
83672 |
2018-06-15 |
693 |
D |
0 |
1 |
GRQ011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of clinical records and policies, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 sample residents (#182) reviewed for medications through a feeding tube. This failure created the potential for harm if complications developed from improper feeding tube practices. Findings include: The facility's policy and procedure for Administering of Medication through an Enteral Feeding Tube, dated 5/28/15, directed staff that if a pump was not being used, check the tube for placement and patency using a 60 ml syringe, then flush with 15 to 30 mls of warm tap water prior to administering medication. Resident #182 was admitted to the facility on [DATE] with multiple diagnoses, including pneumonitis due to inhalation of food and vomit and dysphagia (a swallowing disorder). Resident #182's physician orders, dated 6/14/18 at 5:46 PM, documented the following: * [MEDICATION NAME] sodium tablet (a stool softener) give 100 mg through the tube twice a day. * [MEDICATION NAME] Fast-Max Congest Cough (a decongestant) 2.5-5-100 mg/5 ml give 10 ml through the tube twice a day. * Apixaban (Eliquis) tablet (a blood thinner) give 2.5 mg through the tube twice a day. Resident #182's current care plan documented he had a feeding tube related to dysphagia and directed staff to do the following: Monitor/document/report to physician as needed: aspiration (inhaling material into lungs), fever, shortness of breath, tube dislodged, infection of the tube site, self-removal of the tube, disturbance or malfunction of the tube, abnormal breathing or lung sounds, abnormal lab results, abdominal pain, distension, or soreness, constipation or impaction, diarrhea, nausea/vomiting, or dehydration. On 6/14/18 at 5:30 PM, RN #5 was observed administering medication to Resident #182 through his feeding tube. RN #5 briefly turned the valve on the stopcock to the feeding tube, observed a small amount of mostly clear liquid return in the tube and turned the stopcock back. RN #5 then administered the following medications through the feeding tube: [MEDICATION NAME] 10 mls, [MEDICATION NAME] 10 mls, and Eliquis 2.5 mg. RN #5 did not verify placement or patency of the feeding tube prior to administering medications through the tube. On 6/14/18 at 5:56 PM, RN #5 said she should have checked placement of the feeding tube prior to giving medications, and sometimes she just watched the tube to check placement by turning the stopcock to see return (of stomach contents). |
2020-09-01 |