Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to verify gastrostomy tube placement prior to administering medications to a resident with a feeding tube, as required by facility policy. The nurse entered the resident's room to administer medications via the G-tube but did not check for tube placement or observe the tube site before proceeding. Instead, the nurse checked for residual contents and, finding none, flushed the tube and administered the medications, followed by another flush. The nurse did not use a stethoscope or other approved method to confirm tube placement, which was inconsistent with the facility's written procedures. The resident involved was an elderly female with severe cognitive impairment, dysphagia, protein calorie malnutrition, cerebral infarction, Alzheimer's disease, gastro-esophageal reflux disease, and a history of adult failure to thrive. She was receiving continuous enteral nutrition and had physician orders for specific medications to be administered via the G-tube. The care plan for this resident included monitoring for signs and symptoms of aspiration, infection, and tube dysfunction, and the facility's policies required verification of tube placement before administering any fluids or medications. Interviews with nursing staff and the DON revealed inconsistent understanding and practices regarding tube placement verification. One nurse stated she was told by the DON that checking for residual was sufficient, while another nurse described using both residual checks and a stethoscope. The DON referenced a change in procedure but could not provide clear guidance consistent with written policy, which specified checking tube length, retention device position, and, if available, pH measurement. This failure to follow established protocols placed the resident at risk for complications associated with improper tube placement.