Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, dysphagia, diabetes mellitus, cellulitis, peripheral vascular disease, renal insufficiency, and benign prostatic hyperplasia, who was moderately cognitively impaired and dependent on a G-tube for nutrition, did not receive care in accordance with facility policy and physician orders. During a medication administration, an LPN failed to verify the placement of the G-tube before administering water, medication, and a bolus feeding. The resident was positioned at a 90-degree angle in a chair, rather than the required 30-45 degree angle. Additionally, the LPN used an undated syringe to administer medications and did not dilute the crushed aspirin with water prior to administration through the G-tube. The facility's policy required verification of G-tube placement, proper dilution of medications, use of dated syringes, and correct resident positioning during G-tube medication administration. The LPN involved was unaware of the facility's G-tube policy and confirmed the deviations from protocol, including not checking tube placement, not diluting the medication, using an undated syringe, and incorrect resident positioning. These actions were observed and confirmed through staff interview and policy review.