Failure to Provide and Document Required Gastrostomy Tube Site Care
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube (GT) did not receive appropriate care and services to prevent complications associated with enteral feeding. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with diagnoses including tracheostomy, gastrostomy, and dementia. The resident's care plan required daily GT site care, including cleaning with normal saline, patting dry, and covering with a dry dressing, as well as assessment for signs of infection. Physician orders and facility policy also specified daily care and immediate documentation after completion of the task. On the day in question, multiple observations by staff revealed that there was no dressing present on the resident's GT insertion site, despite documentation in the Treatment Administration Record (TAR) indicating that care had been provided. The treatment nurse confirmed that he had documented the care as completed but was unsure what happened to the dressing, suggesting the resident may have removed it. The Director of Nursing confirmed that if the dressing is not present, the care was not done, and emphasized the requirement for immediate documentation after care. The facility's policy indicated that staff are trained to recognize and report complications related to feeding tubes.