Failure to Verify PEG Tube Placement and Residual Before Medication Administration
Penalty
Summary
A deficiency occurred when an LPN administered crushed oxycodone 5 mg via PEG tube to resident R402 without verifying tube placement or assessing gastric residual immediately prior to medication administration, contrary to facility protocol. On observation, the LPN was seen at 3:55 PM giving the medication through the PEG tube without checking placement or residual, later explaining in interview that these checks had been done earlier in the day and were believed not to require repetition. The DON stated in interview that facility practice requires tube placement and residual to be checked every time before using the PEG tube for medications or feedings. Record review showed that R402 had been admitted with diagnoses including cerebral infarction (stroke), type II diabetes mellitus, pneumonia, tracheostomy, gastrostomy, and adjustment disorder with depression, and had a BIMS score of 12/15 indicating moderate cognitive impairment. Facility documentation titled “Medication VIA Gastrostomy Tube” indicated that tube placement should be checked via auscultation or aspiration. The surveyor determined that this failure resulted in the potential for aspiration and respiratory compromise for R402.
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