Failure to Verify NGT Placement Prior to Medication Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to verify the placement of a nasogastric tube (NGT) prior to administering medication to a resident. During a medication administration observation, the LVN prepared the resident's medications, verified the resident's identity, and attempted to aspirate for gastric residual from the NGT, but no residual was obtained. Despite this, the LVN proceeded to administer the medications through the NGT without further verification of tube placement. When questioned, the LVN stated that checking tube placement was unnecessary for an NGT, as opposed to a G-tube. The resident involved had a history of postpartum cardiac arrest and was care planned to have an NGT, with instructions to check tube placement and gastric contents per facility protocol. The facility's policy required verification of NGT placement by aspirating for gastric contents and, if none were obtained, by injecting air and listening for a swooshing sound with a stethoscope. The Director of Nursing confirmed that all licensed nurses were expected to follow this protocol for both NGT and G-tube placements prior to administering feedings or medications.