Failure to Obtain Physician Orders and Document PEG Tube Care
Penalty
Summary
The facility failed to obtain and maintain current physician orders for the care and monitoring of a resident's percutaneous endoscopic gastrostomy (PEG) tube. The resident, who was severely cognitively impaired and had multiple diagnoses including dysphagia and muscle weakness, was admitted with a PEG tube in place. The care plan included interventions such as cleansing the PEG tube site, applying a dressing, and daily inspection for signs of infection or skin breakdown. However, a review of physician orders for the relevant month revealed there were no active orders for cleansing, inspecting, or dressing the PEG tube site, and a previous order did not specify the type of dressing required. Further review of the Treatment Administration Record showed no documentation that staff had inspected, cleansed, or dressed the PEG tube site for a period of nearly three weeks. A visitor reported observing dried blood around the PEG tube and noted that staff did not return to clean the site after being informed. Observation confirmed the presence of a dressing only on the day of the survey, and an LPN verified the absence of physician orders and documentation for PEG tube care. Facility policies required daily checks of feeding tube sites and physician-specified dressing orders, which were not followed in this case.