Failure to Perform Daily Tube Feed Dressing Changes per Physician Order
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube reported that staff were not changing their tube feed dressing as required. Observation confirmed that the dressing was dated from ten days prior, and a Licensed Practical Nurse (LPN) acknowledged that the dressing had not been changed since that date. The LPN stated that the dressing should be changed daily during the night shift and recognized the risk for infection if the site is not kept clean. Review of the resident's electronic medical record showed a physician order specifying that the enteral tube site should be cleansed with soap and water, rinsed, allowed to air dry, and have split gauze applied, dated, and initialed every night shift. The Director of Nursing (DON) confirmed that the expectation was for nurses to follow these physician orders and that the dressing should have been changed daily. Facility policy also required tube feedings to be managed according to physician orders and current clinical standards of practice.
Plan Of Correction
F 693 Tube Feeding Element #1: Resident #69 dressing was changed. Element #2: Current residents with gastrostomy tubes have the potential to be affected. Current residents with gastrostomy tubes were assessed to ensure that dressings were changed. Any dressing not in place or in need of change was completed. Current residents with gastrostomy tubes' electronic medical records were reviewed to ensure that dressing change orders were in place. Any resident without orders for dressing change orders was entered into the electronic medical record. Element #3: The policy, Tube Feeding - Formula Administration, Flushing, and Unclogging, has been reviewed and deemed appropriate. The policy remains in place. Registered Nurses & Licensed Practical Nurses were re-educated on the policy for Tube Feeding - Formula Administration, Flushing, and Unclogging, with emphasis on gastrostomy tube dressings. Element #4: The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with tube feeding dressing changes. Audits will be conducted weekly for four weeks, then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025