Failure to Provide Timely Treatment and Care Planning for G-Tube-Related Skin Blisters
Penalty
Summary
A resident with a G-tube developed a dime-sized blister below the G-tube site, which was observed by an LPN during medication administration. The LPN attributed the blister to friction from the G-tube tubing being too long and noted that a similar blister had developed several days earlier. The resident's medical record showed diagnoses including cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. Documentation indicated that the blister was possibly due to friction and that the tubing was repositioned and the blister covered, but there was no documentation that the provider had been notified, that treatment orders had been obtained, or that a care plan had been created after either blister developed. Interviews with the Clinical Care Coordinator (CCC) and the Director of Nursing (DON) revealed that the CCC had been verbally notified of the blister but failed to follow up, and neither the provider nor the family had been notified. The resident's plan of care was not updated, and no physician orders were obtained for treatment or prevention. The DON confirmed that a care plan should have been created after the first blister and that the facility did not have a specific policy for provider notification or care plan creation, instead relying on general nursing standards of practice.