Failure to Follow Protocol for G-Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive proper care during medication administration. The resident, who had diagnoses including dysphagia, intracranial hemorrhage, congestive heart failure, gastrostomy, and dementia, was observed receiving multiple crushed medications mixed in water through the g-tube. The LPN administering the medications failed to check the tube for placement and did not flush the tube prior to medication administration, contrary to facility policy. Additionally, the LPN did not provide the ordered 200 mL of water bolus as prescribed, instead flushing the tube with only 60 mL of water after medication administration. Medical record review confirmed the resident was ordered a regular diet with pureed texture, thin liquids, and a specific water bolus twice daily. Facility policy required verification of tube placement, flushing before and between medications, and use of the prescribed amount of water. The LPN acknowledged during interview that these steps were omitted due to forgetting the cup and not wanting to set it down, resulting in failure to follow both physician orders and facility policy for enteral tube medication administration.