F0693

D

Improper Cleaning and Storage of G-Tube Syringe

Pinehurst, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly clean and dry a G-tube syringe before storage for a resident receiving enteral nutrition and medications. The resident had diagnoses including unspecified dysphagia, gastrostomy status, and aphasia following a stroke, and received more than half of her total calories from enteral feedings. Active orders included continuous tube feeding at 72 ml/hr over 20 hours with water flushes every 4 hours. Review of the MAR showed that a nurse administered medications via the G-tube in the morning. Later that morning, surveyors observed the resident’s G-tube flush syringe stored in a plastic bag hanging from the feeding pump pole, labeled as changed at midnight. The syringe was separated from the plunger, but the elongated tip and lower third of the barrel contained thick, crusted yellow material, and the storage bag contained water droplets with pooling at the bottom.

During interview, the nurse who had administered the medications acknowledged that she had observed the syringe was discolored when she used it earlier. She stated that some medications could stain syringes and reported that she rinsed the syringe with water after use but had no supplies to scrub it. She explained that she separated the syringe and plunger and placed them into the storage bag after rinsing, and she was not aware that the syringe and plunger should be allowed to air dry before being placed into a clean, dry bag. The DON later stated that the syringe should have been washed, the plunger removed to allow drying before storage in a dry bag to prevent bacterial growth, and that the stained syringe should have been discarded and replaced, with G-tube syringes routinely replaced on night shift. The report states that this deficient practice had the potential to cause bacterial growth and contamination.