Failure to Update Care Plan for Resident's Peg Tube Behavior
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner for a resident who exhibited behaviors of dislodging a peg tube. The resident, admitted on August 14, 2023, had a medical history including benign neoplasm of the stomach, Alzheimer's disease, gastrostomy status, unspecified protein-calorie malnutrition, and attention-deficit hyperactivity. Despite multiple incidents where the resident dislodged the peg tube, including documented occurrences on March 18, June 11, and December 12, 2024, there was no care plan developed to address this behavior. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change. However, the care plan for this resident was not updated to reflect the behavior of pulling out the peg tube. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the need for the care plan to be revised to address the resident's behavior.
Plan Of Correction
Resident R237 care plan updated to include a comprehensive care plan for identified behaviors. Residents with peg tubes were reviewed for past 14 days for resident behaviors and care plans checked to ensure a comprehensive care plan addressing the behaviors was completed. Staff development/designee re-educated licensed staff on formation of comprehensive care plan when resident observed pulling at peg tube are exhibited. Random audits of residents with peg tube for pulling behaviors care plans will be completed weekly x4 then monthly x2, for a comprehensive care plan for behaviors is in place. Results will be reported to QAPI committee monthly.