Failure to Provide Ordered Tube Feed Dressing Changes and Accurate Documentation
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. Upon observation, the tube feed dressing was found to be dated from over a week prior, indicating it had not been changed daily as ordered. The resident confirmed that the dressing had not been changed, and a Licensed Practical Nurse (LPN) verified that the dressing should be changed every night shift to reduce the risk of infection. Further review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed discrepancies. The records indicated that wound care and bandage changes had been documented as completed on several days when, in fact, the last dressing change had occurred much earlier. The LPN acknowledged that these entries were incorrect and stated that documentation should only occur after care has been provided. The LPN also reported discussing the issue of falsification of records with the Registered Nurse (RN) who had made the entries. The resident's medical history included dysphagia and the presence of a gastrostomy tube, with physician orders specifying daily site care and dressing changes. The Director of Nursing (DON) confirmed that the facility's expectation is for medical records to be accurate and for residents to receive the treatments as ordered. The failure to provide daily dressing changes and the inaccurate documentation led to the identified deficiency.
Plan Of Correction
F 842 Accurate Medical Record ELEMENT #1 Resident #69 dressing was changed and properly documented in the electronic medical record. ELEMENT #2 Current residents with enteral tubes have the potential to be affected by the deficient practice. Current residents with enteral tubes dressings were evaluated to determine if they were changed timely. Any dressing not changed was changed and appropriately documented in the electronic medical records. ELEMENT #3 The policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, and the policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, has been reviewed and deemed appropriate. The policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, 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 enteral tube dressing changes and documentation. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with enteral tube dressing changes and documentation. 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