Failure to Initiate G-Tube Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a gastrostomy tube (g-tube) in accordance with its own care planning policy and procedures. Upon admission, the resident, who had a history of diabetes, transient ischemic attack, and dysphagia, was identified as having a g-tube for feeding due to swallowing difficulties. Record reviews showed that the resident was cognitively impaired, required moderate to total assistance with activities of daily living, and was incontinent of bowel and bladder. Despite these complex needs, there was no care plan initiated for the g-tube feeding upon admission. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed that a care plan for the g-tube should have been created at the time of admission to guide staff in providing appropriate care, such as monitoring for patency, aspiration precautions, infection prevention, and managing bloating. The absence of a care plan meant that staff lacked clear guidelines for the resident's g-tube care, which was not in accordance with the facility's policy requiring a comprehensive, person-centered care plan for each resident based on their assessed needs.