Failure to Verify G-Tube Placement Prior to Medication and Feeding Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to check the placement of a resident's gastrostomy tube (G-tube) prior to administering scheduled water flushes, a liquid nutritional bolus feeding, and morning medications. The resident was documented as severely cognitively impaired and fully dependent on staff for daily care. Physician orders and the resident's care plan required that the G-tube placement and gastric residual be checked and recorded before administering any feedings or medications. The LPN did not follow these orders or the facility's policy, which specifically instructed staff to verify G-tube placement before administering medications. Interviews with the LPN and the Director of Nursing (DON) confirmed that the required checks were not performed prior to the administration of substances through the G-tube. Both staff members acknowledged that there was no way to confirm whether the administered substances entered the resident's stomach as intended, since the placement was not verified. The facility's policy, revised in February 2024, also required checking G-tube placement before medication administration, which was not followed in this instance.