Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications administered via a gastrostomy tube were provided in accordance with professional standards and facility policy. The facility’s Medication Administration policy, last reviewed on December 31, 2025, required that gastrostomy tube placement be confirmed by auscultation with air prior to medication administration. Resident 46’s clinical record showed diagnoses including acute and chronic respiratory failure with hypoxia, ventilator dependence, and the presence of a gastrostomy tube. The physician’s order for this resident directed that feeding tube placement be confirmed prior to every instillation of tube feeding, medications, water, etc., each shift, and that placement be confirmed per policy. During a medication administration observation for Resident 46 on January 22, 2026, at 8:45 AM, a Registered Nurse (Employee 3) administered medications through the resident’s gastrostomy tube without confirming tube placement beforehand. In a subsequent interview, Employee 3 stated that the facility previously had a policy requiring verification of gastrostomy tube placement before medication administration but believed that policy was no longer in effect. In an interview later that morning, the DON confirmed that Employee 3 should have verified the gastrostomy tube placement before administering the medications, indicating that the nurse’s actions did not follow the current policy and physician order.
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