Failure to Verify PEG Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to verify the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administering medications to a resident. During a medication administration observation, the RN administered MiraLAX, potassium chloride, and ibuprofen via the PEG tube without confirming its placement, contrary to the facility's policy and professional standards of practice. The RN later acknowledged in an interview that verifying PEG tube placement is necessary to ensure correct positioning and prevent complications. The resident involved had a history of gastrostomy status and physician orders for multiple medications to be administered via the PEG tube. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition. The acting Director of Nursing (DON) confirmed in an interview that the RN should have verified PEG tube placement before administering medications and that failure to do so could result in complications.