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F0693
D

Failure to Flush G-Tube Before and After Medication Administration

Johnston, Iowa Survey Completed on 09-17-2025

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 registered nurse failed to follow facility policy regarding the administration of medication through a gastrostomy tube (g-tube) for a resident with multiple complex medical conditions, including muscular dystrophy, respiratory failure, dysphagia, malnutrition, a suprapubic catheter, and a tracheostomy. The nurse administered a syringe containing three medications mixed with an unspecified amount of water directly into the resident's g-tube without flushing the tube with water before or after the medication administration, as required by facility policy. Facility policy, revised on 9/16/25, specifies that the enteral tube should be flushed with at least 15 ml of water prior to and after administering medications. The nurse stated there was no set amount for the water flush and indicated it did not matter, which was inconsistent with both the policy and the Director of Nursing's expectations. The Director of Nursing confirmed that, in the absence of a specific physician order, the protocol is to flush with 30 or 60 ml of water before and after medication administration.

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