Failure to Assess and Monitor G-Tube Site Leading to Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident's gastrostomy (g-tube) site and provide appropriate interventions for skin irritation. The resident, who had multiple comorbidities including diabetes, stroke, hemiplegia, malnutrition, and was at high risk for pressure ulcers, required substantial assistance with mobility and was dependent on staff for all transfers and personal care. Orders were in place for staff to monitor the skin around the g-tube site and change the dressing every shift, as well as to conduct weekly skin inspections by a licensed nurse. Documentation showed that staff signed off on these tasks, but interviews and record reviews revealed gaps in the thoroughness and accuracy of these assessments. Nursing staff, including LPNs, reported that weekly skin assessments were sometimes performed without fully removing the resident's clothing, limiting the ability to visualize the entire body and the g-tube site. The LPN responsible for weekly assessments admitted to relying on nursing assistants to report skin issues and was unsure of the full requirements for the assessment. She noted minimal red bloody drainage on the g-tube dressing over several weeks but did not document this finding. The facility's wound care provider and DON confirmed that staff were expected to perform head-to-toe assessments with clothing removed and to document and report any skin concerns, including those at the g-tube site, but this was not consistently done. The resident was later hospitalized with altered mental status, hypotension, and signs of infection. Hospital records documented redness, purulent drainage, and erosion at the g-tube site, with cultures growing bacteria. Interviews with facility staff indicated that the nurse practitioner was unaware of the g-tube site irritation and would have expected to be notified. The facility's enteral tube site care competency outlined specific steps for assessment and care of g-tube sites, including cleaning, inspection, and documentation, but these procedures were not fully followed, leading to the deficiency.