Failure to Reassess and Remove Unused PEG Tube
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and a percutaneous endoscopic gastrostomy (PEG) tube was not managed according to current standards of practice. The resident had a PEG tube placed during a hospital stay due to dysphagia and was admitted to the facility with the tube in place. Provider orders indicated the resident was to receive a dysphagia diet and enteral water flushes, but there were no current orders for PEG tube care, feeding, or medication administration through the tube. Documentation showed the resident was consuming regular meals and no longer required tube feeding since January, yet the PEG tube remained in place and was only being maintained with water flushes and site cleaning. During interviews, the resident confirmed that the PEG tube had not been used for nutrition for several months and that staff had informed her it might be removed soon. The nurse practitioner acknowledged forgetting to reassess the need for the PEG tube, despite it no longer being used for its original purpose. The director of nursing stated the tube was being kept as a precaution due to the resident's risk of another stroke. The failure to reassess and remove the unused PEG tube, and the lack of updated provider orders for its care, constituted the deficiency.