Failure to Implement and Document G-Tube Care Orders
Penalty
Summary
Nursing staff failed to implement physician's orders and hospital discharge recommendations regarding the care and flushing of a resident's gastrostomy/jejunostomy (G-tube) feeding tube. The resident, who had diagnoses including left hemiparesis, dysphasia, a gastrostomy tube, and glioblastoma multiforme, required specific management of the G-tube, including flushing the jejunostomy port with 60 ml water at least every four hours and flushing the gastrostomy port with 60 ml water after administering medications. Despite these clear instructions, record reviews showed that the required care was not documented or carried out, as evidenced by blank entries in the electronic medication administration records (e-MAR) over several months. The deficiency was further substantiated by multiple documented incidents of the resident's G-tube becoming clogged, which led to repeated hospital visits. During interviews, the DON confirmed that the instructions were not implemented by licensed nurses, as indicated by the lack of documentation in the e-MAR. The failure to follow physician's orders and properly document care resulted in the resident experiencing frequent G-tube clogging.