Failure to Flush G-Tube Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including multiple sclerosis, aphasia, anoxic brain damage, and dysphagia, did not receive appropriate care during medication administration via a gastrostomy tube. The facility's policy requires that enteral tubes be flushed with at least 15 ml of water before administering any medications and after medications have been given. However, during direct observation, the LPN prepared and administered the resident's medications through the G-tube without flushing the tube with water prior to administering the first medication, specifically Vitamin D. The LPN did flush the tube between medications and after administration, but failed to perform the initial flush as required by policy. The resident was severely cognitively impaired, as indicated by a BIMS score of 0, and was dependent on tube feeding per physician order. The LPN acknowledged the omission when questioned, attributing it to a lapse in memory and nerves. The failure to flush the G-tube prior to medication administration was directly observed by the surveyor and was not in accordance with the facility's established procedures for safe and effective enteral medication administration.