Federal inspectors observed the violation on September 15 at Bishop Drumm Retirement Center during a complaint investigation. The nurse, identified as Staff A, sat on the side of Resident #15's bed and injected approximately 25 milliliters of pink liquid medication into the resident's gastrostomy tube without any water flush.
Resident #15 required extensive medical support. The 69-year-old had muscular dystrophy, respiratory failure, difficulty swallowing, and malnutrition. A surgically implanted feeding tube provided nutrition and medication directly to the stomach. The resident also had a tracheostomy tube for breathing and a suprapubic catheter for urination, requiring complete staff assistance for eating, toilet hygiene, and transfers.
When questioned, Staff A stated the pink liquid contained three of the resident's medications mixed with "an unknown amount of water." The nurse explained there was "no set amount for the water flush so it didn't really matter."
This contradicted the facility's own medication administration policy, revised just one day later on September 16. The written protocol explicitly required staff to "flush enteral tube with at least 15 ml. of water prior to administering medications" and "flush tube again with at least 15 ml. water" afterward.
Proper flushing prevents medication residue from accumulating inside feeding tubes, which can cause dangerous blockages requiring surgical intervention. The water flushes also ensure complete medication delivery to the resident's stomach rather than leaving doses trapped in the tubing.
The Director of Nursing confirmed the facility's expectations during a September 16 interview. She stated staff should follow physician orders for g-tube flushing, or if no specific order exists, follow the standard protocol requiring "30 or 60 ml. of water to flush before and after medications given."
Her stated protocol actually exceeded the written policy's 15-milliliter requirement, suggesting even greater emphasis on thorough flushing procedures.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to few residents. However, the failure occurred with a particularly vulnerable patient who depended entirely on staff for basic care and had mild cognitive impairment that limited self-advocacy.
Resident #15's complex medical conditions made proper tube maintenance especially critical. Muscular dystrophy had already compromised swallowing ability, necessitating the feeding tube placement. Respiratory failure meant any aspiration from tube malfunction could prove life-threatening.
The timing raised additional concerns. Staff A performed the improper medication administration while federal inspectors conducted a complaint investigation at the facility. The violation occurred despite heightened scrutiny and the nurse's awareness of regulatory oversight.
Bishop Drumm Retirement Center houses 114 residents in Johnston, a suburb northwest of Des Moines. The September inspection followed a specific complaint, though federal records don't specify the nature of the original allegation that triggered the investigation.
The facility's medication policy had been recently updated, revised on September 16, just one day after inspectors observed the violation. Whether the policy revision responded to the observed failure or represented routine updates wasn't specified in inspection documents.
Federal regulations require nursing homes to ensure feeding tubes aren't used unnecessarily and receive appropriate care when medically indicated. The rules specifically mandate proper maintenance to prevent complications that could harm residents or require emergency interventions.
Staff A's casual dismissal of flushing requirements—stating the water amount "didn't really matter"—suggested potential gaps in training or supervision around feeding tube protocols. The comment indicated either insufficient understanding of the medical rationale for flushing or disregard for established safety procedures.
For Resident #15, the medication administration failure represented just one risk among many daily medical interventions. The resident's dependence on a tracheostomy, feeding tube, and catheter created multiple opportunities for staff errors to cause serious harm.
The inspection found Bishop Drumm failed to provide appropriate care for a resident with a feeding tube, specifically by not following established flushing protocols designed to prevent complications and ensure proper medication delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Drumm Retirement Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
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