Failure to Assess and Monitor PEG Tube Site and Timely Obtain Admission Weight
Penalty
Summary
A deficiency occurred when a resident with a percutaneous endoscopic gastrostomy (PEG) tube did not receive proper assessment and monitoring of the tube insertion site. During an observation, the resident was found with a reddened, raised area at the PEG site, which had gone unnoticed by nursing staff. The family reported that they had placed a dressing on the site themselves after noticing the area looked sore, and expressed concerns that nurses were not checking the site. The dressing was undated, and the resident indicated pain when the area was examined. Record review revealed that there were no physician orders for PEG site care upon admission, and no documentation of assessments or care of the PEG site in the resident's medical record. The facility's policy required daily checks and documentation of the enteral retention device and surrounding skin, but this was not followed. Additionally, the resident's admission weight was not obtained until five days after admission, despite policy requiring weights to be taken upon admission. The registered dietician and DON confirmed the delay in obtaining the weight and the lack of documentation for PEG site care. Further review showed that enteral nutrition orders were not in place until 24 hours after admission, and the resident received a different enteral formula than what was indicated on the hospital discharge summary until the correct product arrived. The DON acknowledged that the nurse failed to enter the tube feeding order on the day of admission and that documentation of PEG site assessments was missing. The facility's documentation practices did not capture the required ongoing assessment of the PEG site, and the initial nursing admission assessment did not include a skin assessment of the PEG insertion site.