Failure to Follow PEG Tube Medication Administration Protocol
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow physician orders and facility policy regarding percutaneous endoscopic gastrostomy (PEG) tube care for a resident. The nurse did not check the placement of the PEG tube or assess for residual prior to administering medication, nor did the nurse flush the tube with the prescribed amount of water before medication administration. These actions were observed during a medication pass and confirmed in a subsequent interview with the nurse. The resident involved had diagnoses including protein-calorie malnutrition, gastrostomy status, and cognitive communication deficit, but was noted to have intact cognition. Physician orders required checking PEG tube placement and residual, documenting the residual, and flushing the tube with 60 ml of water before and after medication administration. Facility policy also outlined steps for checking tube placement and residuals. These procedures were not followed during the observed medication administration.