Failure to Accurately Document PEG Tube Site Assessments
Penalty
Summary
The facility failed to ensure that two residents with PEG tubes received treatment and care in accordance with professional standards of practice. Specifically, the weekly skin integrity assessments for both residents did not accurately document the presence or condition of their PEG tube sites on multiple occasions, despite physician orders requiring daily cleaning and dressing of the sites. The electronic medical records for these residents showed that the required skin assessments did not reflect the PEG tube wounds as mandated by facility policy and physician orders. Both residents had significant medical histories, including hemiplegia, chronic respiratory failure, malnutrition, and dementia, and were nonverbal or rarely understood. During interviews, the LPN/Treatment Nurse acknowledged that the skin assessments for these residents were not completed accurately and admitted to simply clicking through the electronic assessments without proper documentation of the PEG tube sites. This failure resulted in the lack of accurate and complete skin integrity reviews for residents with feeding tubes, contrary to facility policy and professional standards.