Failure to Ensure Proper G-Tube Care and Infection Control
Penalty
Summary
The facility failed to provide proper care and treatment for gastrostomy tube (G-tube) management for two residents. For one resident with dementia, diabetes, and depression, the head of bed (HOB) was not elevated to the required 30 to 45 degrees during G-tube feeding, as specified in the physician's order and care plan. Observations showed the resident lying flat in bed while receiving tube feeding, and staff interviews confirmed that the HOB was not elevated as required. Facility policy also required the resident to be in a semi-Fowler's position during and after tube feeding. For another resident with dysphagia, diabetes, and anemia, the facility failed to maintain a clean valve on the G-tube. During observation, the valve was found to be dirty with black dry discoloration. Staff interviews confirmed that a dirty valve was not acceptable due to infection control concerns. It was also revealed that the facility did not have a policy or procedure in place for maintaining the cleanliness of the valve, despite having a general infection prevention and control program. Both deficiencies were identified through observation, record review, and staff interviews. The lack of adherence to physician orders, care plans, and infection control practices led to the findings for both residents.