Failure to Assess and Monitor G-Tube Placement in Resident with Known Risk Behaviors
Penalty
Summary
A deficiency occurred when nursing staff failed to assess and check the placement of a resident's gastrostomy (G-tube) as required by facility policy. The resident, who had diagnoses including Alzheimer's disease, severe protein calorie malnutrition, anorexia, and was fully dependent on staff for all activities of daily living, had a history of agitation and repeatedly attempting to pull out her G-tube. Despite these known behaviors and the facility's policy requiring G-tube site assessment every four hours and at the start of each shift, staff did not perform the required checks. On the morning in question, both the LVN and RN on duty did not assess the G-tube site at the start of their shifts, citing that the resident was sleeping and the abdominal binder was in place. The LVN only became aware of the dislodged G-tube after being notified by a CNA, who discovered the issue when the resident complained of stomach pain. The delay in assessment meant it was unclear how long the G-tube had been dislodged, and the resident required an emergency room visit for reinsertion of the tube. Interviews with staff and the resident's responsible party confirmed that the resident had a known pattern of pulling at her G-tube and that the responsible party had previously requested increased monitoring. The facility's policy on enteral feedings clearly stated the need for frequent assessment of the G-tube site, but this was not followed, resulting in a delay in care and the resident experiencing discomfort and pain during the reinsertion procedure.