Failure to Follow Physician Orders for G-Tube Flushes
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for gastrostomy tube flushes for a resident with a history of traumatic brain injury, dysphagia, and a gastrostomy tube. Physician orders specified that the feeding tube should be flushed with 30 mL of water before and after each medication pass, at least 15 mL between each medication, and 30 mL prior to feeding, every 4 hours during continuous feeding, and at the end of each feeding. Record review of the Medication Administration Record (MAR) for October revealed that, during medication administration, only 30 mL of water was administered for 91 out of 93 shifts, and during continuous feedings, only 30 mL was administered for 31 out of 33 shifts, with one shift receiving only 22 mL. This documentation did not align with the specific physician orders for flushes. Staff interviews further confirmed the deficiency. An LPN stated that she administered only 15 mL of water before and after medication administration, which did not meet the physician's orders. The physician also acknowledged that the flushes during medication administration and continuous tube feeding were not completed as ordered. These findings were based on a community complaint and subsequent review of records and staff interviews.