Failure to Verify PEG Tube Placement Prior to Enteral Feeding
Penalty
Summary
A deficiency occurred when a licensed nurse administered a bolus feeding to a resident with a percutaneous endoscopic gastrostomy (PEG) tube without first verifying the tube's placement, as required by physician orders and facility policy. The nurse checked for bowel sounds and residual amount but omitted the step of confirming PEG tube placement prior to starting the enteral feeding. During the feeding, the resident exhibited intermittent coughing. The nurse later acknowledged not checking the tube placement and recognized the importance of this step to ensure the tube was correctly positioned in the stomach before administering the feeding. The resident involved had a history of diabetes mellitus, gastroesophageal reflux disease, and required ongoing attention to a gastrostomy. The resident was cognitively moderately impaired and dependent on tube feeding and water flushes, as documented in the care plan. Facility policy and physician orders specifically required verification of tube placement before each feeding, but this protocol was not followed during the observed incident. Interviews with facility leadership confirmed that checking tube placement is the expected standard of practice to prevent complications.