Failure to Appropriately Verify Feeding Tube Placement Prior to Medication and Feeding Administration
Penalty
Summary
The facility failed to ensure that residents with gastrostomy tubes received appropriate care and services to prevent complications related to enteral feeding. Specifically, licensed nurses did not properly verify the placement of gastrostomy tubes prior to administering medications and enteral feedings for three residents reviewed. Instead of aspirating gastric contents to confirm tube placement, nurses routinely injected air into the tube and listened for a gurgling sound with a stethoscope, as per facility practice and policy at the time. This method was used during direct observations of medication and feeding administration for residents with diagnoses including gastrostomy status, dysphagia, malnutrition, Parkinsonism, and traumatic brain injury. Interviews with nursing staff and facility leadership confirmed that the standard practice was to check tube placement by auscultation after air injection, and that staff were not instructed to verify placement by aspirating gastric contents or checking for gastric residuals. The facility's policies on medication administration and gastrostomy tube feeding also directed staff to use the auscultation method. The Director of Nursing acknowledged that the policy had only recently changed and that prior to this, staff were not trained to use aspiration to verify tube placement.