Failure to Verify G-Tube Placement and Residual Before Medication Administration
Penalty
Summary
Two residents with gastrostomy tubes (g-tubes) were not provided appropriate treatment and services to prevent complications of enteral feeding. Both residents had physician orders and care plans requiring verification of g-tube placement and checking for gastric residual prior to medication administration. On the observed date, an LVN prepared and administered medications via g-tube to both residents without performing these required checks. For the first resident, who had severe cognitive impairment and dysphagia, the LVN prepared the medication, dissolved it in water, and administered it through the g-tube after flushing, but did not verify tube placement or check for residual as ordered. The resident's care plan and physician orders specifically required these steps to be performed every shift. The second resident, who was unable to complete a cognitive interview and had a diagnosis of gastrostomy status, also received medications via g-tube from the same LVN without verification of tube placement or checking for residual, despite similar orders and care plan interventions. During interviews, the LVN acknowledged forgetting to perform the required checks and described the correct procedure, while the DON and ADON confirmed that staff are expected to verify g-tube placement and check residual before administering medications. The facility's policy also required confirmation of tube placement and checking gastric residual volume as part of enteral nutrition management.