Improper Bolus G-Tube Feeding Administration and Failure to Follow Physician Order
Penalty
Summary
The facility failed to administer a gastrostomy tube feeding according to the physician’s order and facility policy for one resident receiving bolus tube feedings. The facility’s policy for gastric tube feeding via syringe (bolus) required verification of the physician’s order for product and volume, review of the resident’s care plan, and administration of the prescribed amount of feeding and water by gravity flow using a syringe without a plunger, followed by clamping the tube before detaching the syringe. The resident had a physician’s order for Jevity 1.5 Cal, 300 ml bolus feedings every six hours. During observation, an LPN stated the resident received 600 ml of feeding and proceeded to use a syringe with a plunger to push 600 ml of Jevity 1.5 Cal into the resident’s gastrostomy tube, rather than allowing it to flow by gravity. Between drawing up each syringe of feeding, the LPN attempted to hold the gastrostomy tube with one hand, then laid the unclamped tube on the resident’s lap, causing feeding to leak out onto the resident. The LPN later confirmed that the physician’s order was for 300 ml, not 600 ml, and acknowledged that the tubing had been left unclamped during administration, resulting in leakage. The DON confirmed that physician orders should be followed for enteral feeding volume and that bolus feedings should be administered by gravity flow.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.