Failure to Follow G-Tube Protocols for Enteral Nutrition
Penalty
Summary
A deficiency was identified when staff failed to follow proper procedures for the care and management of a gastrostomy tube (G-tube) for a resident with significant medical needs, including dysphagia, type 2 diabetes mellitus, and heart failure. The resident was totally dependent on staff for daily care and was receiving nutrition via a feeding tube. Physician orders and the resident's care plan required staff to check tube placement and patency every shift, as well as to check gastric residual volume (GRV) before administering feedings. During an observation, a Licensed Vocational Nurse (LVN) was seen preparing to administer a tube feeding to the resident. The LVN did not disinfect the tip of the G-tube or the extension feeding port prior to connecting the feeding, and also failed to check the GRV or the patency of the tube before starting the feeding. The LVN acknowledged that not performing these checks could result in feeding being administered incorrectly, potentially leading to complications for the resident. Interviews with nursing staff confirmed the importance of disinfecting the G-tube and checking placement and GRV for infection control and to prevent complications. Review of the facility's policy on enteral nutrition also indicated that staff should confirm tube placement and check GRV as part of standard care. The failure to follow these procedures constituted a deficiency in the care and treatment of the resident's G-tube.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/11/25, LVN 4 disinfected the G-Tube tubing tip. DSD checked resident 28 was checked for residual prior to connecting the G-Tube Feeding on 06/11/25. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD rounded on 06/11/25 for all other gastric tube residual and found no other resident affected by same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: Starting 7/01/25, LVN 4 will be observed q monthly by Pharmacy Consultant and random medication pass with medication review and cart check twice a month per regulation. On 6/16/25, LVN 4 was given a 1:1 in-service to properly disinfect extension tubing at enteral feeding port also showed proficiency with checking Gastric Volume Residual with DON and Pharmacy Nurse Consultant. Medication Administration Clinical Competency Skills check for all licensed nurses done by DON from 6/19/25 to 7/04/25 and found no other residents affected by same deficient practice. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, the DON will immediately correct any issues reported by Pharmacy Consultant and all findings will be reviewed by Administrator and reported to QAPI monthly meetings for compliance for 3 months. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, the DON will immediately correct any issues reported by Pharmacy Consultant and all findings will be reviewed by Administrator and reported to QAPI monthly meetings for compliance for 3 months.