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F0693
D

Failure to Administer Prescribed Water Flush for GTube Resident After Medication

South Pasadena, California Survey Completed on 07-24-2025

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 resident with a gastrostomy tube (GTube) did not receive the prescribed amount of water flush after medication administration. The resident, who was dependent on tube feeding for all nutrition and hydration and had severely impaired cognitive skills, was observed receiving only 5 cc of water flush after medications, despite physician orders and the care plan specifying 30-50 cc of water before and after medication administration. The resident's care plan also included interventions to ensure adequate hydration and nutrition through proper tube flushing. The Licensed Vocational Nurse (LVN) responsible for administering the medications acknowledged that the correct amount of water flush was not provided and stated awareness of the importance of following the physician's order to prevent tube clogging and ensure proper medication administration. The facility's policy on enteral nutrition also required that nutritional support be provided as ordered. The Director of Nursing confirmed that water flushes are to be given as ordered, but the observation and record review demonstrated that the prescribed protocol was not followed for this resident.

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