Failure to Follow Physician Orders for GT Flushing
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow physician orders for gastrostomy tube (GT) care for a resident with severe cognitive impairment, diabetes mellitus, and dementia. During a medication pass, the LVN flushed the resident's GT with only 30 milliliters (mL) of water before and after administering medications, instead of the prescribed 50 mL. The LVN acknowledged the error, stating she was nervous and did not follow the physician's order, despite being responsible for verifying the correct amount prior to administration. The resident's care plan required nurses to provide fluids via GT as ordered to maintain adequate nutritional intake and prevent dehydration. The Director of Nursing confirmed the importance of adhering to physician orders, noting that the facility policy specified 30 mL but the nurse was required to follow the current physician order of 50 mL. The facility's job description for medication nurses also required treatments to be performed according to physician orders. This failure to follow prescribed GT flushing protocols was identified through observation, interview, and record review.