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F0658
D

Failure to Verify G-Tube Placement Prior to Medication Administration

Studio City, California Survey Completed on 06-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a licensed vocational nurse (LVN) failed to verify the placement of a resident's gastrostomy tube (g-tube) prior to administering medications. The resident, who had diagnoses including Alzheimer's disease, dementia, and required attention to a gastrostomy, was unable to make decisions and had limited ability to communicate. The resident's care plan specifically included interventions to check and maintain the placement and patency of the g-tube. During medication administration, the LVN prepared and administered medications via the g-tube but did not use a stethoscope to confirm tube placement, as required by both facility policy and the resident's care plan. The LVN acknowledged during an interview that the standard procedure was to use a stethoscope to listen for proper g-tube placement before administering medications, but this step was omitted. The Director of Nursing confirmed that the facility's process required verification of g-tube placement to ensure safe medication administration. Facility policy also outlined the need to verify tube placement prior to administering medications through an enteral tube. This failure to follow professional standards of practice and facility policy constituted a deficiency in care for the resident.

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