Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
Nursing staff failed to follow facility policy and procedures for administering medications via a gastrostomy tube for one resident. During a medication pass, the registered nurse did not verify tube placement or check residual volume prior to administering medications, despite a physician's order requiring verification of tube placement before feeding and medication administration. The nurse also administered medications by pushing them through the tube with a syringe, rather than allowing them to flow by gravity as required by facility policy. Water and medication liquid were observed seeping from the tube onto the resident's abdomen during the process, and the nurse wiped the excess fluid off several times. Interviews with the nurse and the Director of Nursing confirmed that the correct procedure was not followed, including the need to check tube placement, residual volume, and to administer medications by gravity. The facility's policy and procedure outlined specific steps for confirming tube placement, checking gastric residual volume, and administering medications by gravity flow, none of which were properly followed during the observed medication administration for the resident with a G-tube.