Lack of Physician Orders for Feeding Tube Water Flushes During Medication Administration
Penalty
Summary
The facility failed to have physician orders specifying the amount of water to flush a feeding tube when administering medications for a resident with a feeding tube. The resident in question had a history of traumatic brain injury, subdural hemorrhage, altered mental status, persistent vegetative state, and dysphasia, and was dependent on staff for mobility and transfers. The resident's care plan indicated tube feeding with specific instructions to check tube placement and gastric residuals per facility protocol, but there was no documented order for the amount of water to use for flushing during medication administration. Observations and interviews revealed that nursing staff administered medications via the resident's feeding tube using water flushes based on facility protocol, but without a specific physician order for the water amount. Staff reported using 30 mL of water to dissolve medications and additional flushes before, between, and after medication administration, following the facility's policy. However, the policies themselves were outdated, and staff could not locate them at the nurses' station or on the medication cart. The Director of Nursing (DON) and Corporate Nurse acknowledged that staff were expected to follow the policy, but there was no documentation of physician orders for water flush amounts or of staff education on the policy. Additionally, there was inconsistency in practice regarding checking for gastric residuals and tube placement, with staff reporting changes to their routine only after being questioned by surveyors. The DON stated that the physician had previously indicated residual checks were not required, but there was no documentation to support this. The lack of clear, accessible policies and specific physician orders for water flushes during medication administration led to the deficiency identified by surveyors.