Failure to Provide Appropriate Care for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident with a percutaneous endoscopic gastrostomy (PEG) tube received appropriate treatment and services to prevent potential complications. The resident was admitted with a PEG tube for nutritional support due to weight loss and failure to thrive, with physician orders specifying a gradual increase in tube feeding rate. However, the orders were not updated to reflect the current running rate, and there was no clear documentation of the actual rate being administered. The care plan directed staff to refer to physician orders for current feeding instructions, but these orders were unclear and did not specify parameters for tube feeding downtime to allow for oral intake, despite the resident also being on a regular, pureed diet. Observations revealed that the tube feeding pump was left unattended and alarming, with the delivery tubing disconnected and uncapped, resulting in formula dripping onto the floor. Staff interviews confirmed that the tubing was left uncapped and that the feeding rate was not clearly documented or communicated. The registered dietician and DON both acknowledged the lack of clarity in the orders and care plan, and the inability to determine the current feeding rate or appropriate downtime for oral intake. These actions and omissions resulted in the resident not receiving care consistent with physician orders, facility policy, or current standards of practice.