Failure to Manage G-Tube and Educate Licensed Staff
Penalty
Summary
The facility failed to properly manage a resident's gastrostomy/jejunostomy (GJ) feeding tube and did not provide adequate education to licensed nursing staff regarding G-tube management. Over a six-month period, the resident, who had a history of left hemiparesis, dysphasia, a G-tube, and glioblastoma multiforme, experienced repeated issues with the GJ tube, including frequent clogging, dislodgement, tearing, and rupture. Documentation showed multiple incidents where the tube was clogged, pulled out, or damaged, and the resident was often administered medications in capsule and tablet form, which may have contributed to the tube's frequent clogging. The DON acknowledged that such persistent problems with a G-tube were not typical and could not explain why the issues persisted or why medications were not adjusted to prevent clogging. Additionally, the facility did not provide education on G-tube management to licensed nursing staff during the relevant period. Review of the facility's education binder and interviews with the director of staff development (DSD) confirmed that no training on enteral feeding or G-tube management was conducted for licensed nurses in 2024. An in-service session on enteral feeding was held, but attendance records showed that only one registered nurse and one assistant director of nursing participated, with the majority of attendees being certified nursing assistants. This lack of education for licensed staff contributed to the ongoing issues with the resident's G-tube.