Failure to Provide Ordered Gastrostomy Tube Site Care
Penalty
Summary
The facility failed to provide necessary care and services for gastrostomy tube (GT) sites as ordered by physicians and as indicated in the care plans for two residents. Both residents had significant neurological impairments, including hemiplegia, hemiparesis, and severely impaired cognition, and were dependent on staff for most activities of daily living. Physician orders and care plans for both residents required licensed staff to clean the GT site with normal saline solution, pat dry, cover with a drain sponge, and secure with retention tape daily and as needed. Care plans also specified GT site care per protocol every shift and as needed, with goals to keep the GT insertion site free from infection and complications. Direct observations revealed that neither resident had a drain sponge dressing or securement at the GT site at the time of inspection. Staff interviews confirmed that the GT sites were not covered or secured as ordered. The facility's policy and procedure for gastrostomy site care required the application of a T-drain sponge and retention tape to promote cleanliness and protect the site from irritation, breakdown, and infection. The Director of Nursing confirmed that the GT site should be kept clean, covered, and secured as ordered to prevent infection, dislodgement, and skin irritation.