Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow physician orders for administering medications via gastrostomy tube to a resident. The LVN did not flush the gastrostomy tube with the prescribed 5-10 mL of water between each medication, as required by the resident's orders and facility policy. Instead, the LVN flushed the tube only before and after administering all medications, omitting the necessary flushes between each medication. Additionally, the LVN left residual medication in five cups, indicating that the full doses were not administered to the resident. The resident involved was an elderly female with diagnoses including hypertension and anemia, and was receiving nutrition and medications through a feeding tube. The LVN was aware of the correct procedure but stated she forgot to flush between medications and realized there was residual medication left after administration. Record review showed the LVN had not attended the most recent g-tube medication administration training. Facility policy and physician orders both required individual administration of medications with appropriate flushing between each dose, which was not followed in this instance.