Failure to Verify Enteral Tube Placement Before Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s care and treatment of a resident with an enteral feeding tube when staff failed to verify tube placement prior to administering medication. The facility’s “Medication Administration Enteral Access Device” policy, released 9/16/25, directed staff to follow general professional standards for safe administration of medications and to verify tube placement per facility protocol. The resident, admitted with diagnoses including paraplegia and dysphagia, had a physician’s order dated 1/21/26 specifying that medications may be crushed or given in liquid form via the enteral tube and that tube placement must be checked via auscultation before medication administration. On 4/1/26 at 9:00 AM, an RN administered 30 mL of water through the resident’s enteral tube, followed by 20 mL of liquid hydroxyzine HCl, and then flushed the tube with 30 mL of water, without verifying tube placement beforehand. When interviewed shortly afterward, the RN stated she was unsure of the facility’s policy on checking tube placement and residual prior to administering medications, and the CNO reported that the facility’s G-tube policy did not require checking residual or placement before feedings or medication administration, indicating placement was only checked by x-ray at the time of insertion. This failure to verify tube placement before medication administration was determined to be a lack of adequate care and treatment for the resident reviewed for enteral tube use, creating the potential for harm if complications developed from improper medication administration via the enteral access device.
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