Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to check the placement of a resident's gastrostomy tube (g-tube) prior to flushing it with water and administering medications. The nurse did not aspirate for gastric contents or measure the tube from the insertion site to the end, as required by facility policy and physician orders. Instead, the nurse proceeded to flush the tube and administer medications, even encountering resistance while pushing water into the tube. The nurse later acknowledged that she did not check tube placement before administering medications. The resident involved had severe cognitive impairment, was dependent on staff for all care, and received the majority of nutrition and hydration via the g-tube due to multiple diagnoses including dementia, end stage renal disease, and dysphagia. Facility policy and physician orders required daily measurement of the g-tube to confirm placement and mandated checking tube placement before medication administration. Interviews with staff and review of facility policies confirmed that the expected practice was not followed during the observed medication administration.