Failure to Follow Feeding Tube Placement and Infection Control Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper procedures during feeding tube site care for a resident with a history of hemiplegia, dysphagia, and malnutrition. The resident, who had severe cognitive impairment and required assistance with all activities of daily living, had orders for checking tube placement prior to medication administration, flushing the tube with water every shift, and maintaining the site with a split drain sponge and antibiotic ointment. During an observed care episode, the LPN performed hand hygiene and donned PPE before entering the room, but placed care supplies on an unprotected chair instead of a clean barrier. The nurse did not check the feeding tube placement before flushing it, as required by facility policy and physician orders. Additionally, after removing the old dressing, the nurse failed to perform hand hygiene or change gloves before handling supplies, touching the resident's drawer, and applying ointments to the feeding tube site, resulting in multiple breaches of infection control protocol. Interviews with the LPN and the DON confirmed that the nurse did not follow required procedures for verifying tube placement and maintaining hand hygiene and glove changes after contact with potentially contaminated surfaces. Facility policies specified the need for clean technique, use of barriers, and hand hygiene at specific steps, all of which were not followed during the observed care, placing the resident at risk for infection.