Failure to Ensure Proper Gastrostomy Tube Practices and Procedures
Penalty
Summary
The facility failed to implement proper gastrostomy tube (GT) practices and procedures for two residents. For one resident with a history of hemiplegia, hemiparesis, acute respiratory failure, and dementia, the head of bed was observed to be elevated at only 20 degrees during enteral feeding, despite physician orders and care plan interventions requiring elevation to at least 30-45 degrees. The Director of Nursing confirmed that the observed bed elevation was below the required angle, and facility policy also specified a minimum of 30 degrees during enteral feedings. For another resident with diagnoses including gastrostomy, dementia, and dysphagia, the GT feeding was not properly connected, resulting in Glucerna leaking into the resident's bed and onto the floor. The resident was dependent on staff for most activities and received more than half of their nutrition through the feeding tube. The nurse present acknowledged that the feeding should not be leaking and that staff are responsible for ensuring all tubing is properly connected so the resident receives the prescribed nutrition. Facility policy required that enteral feedings be administered as ordered by the attending physician, with procedures to check tube placement and ensure proper connection of feeding containers and tubing. The Director of Nursing confirmed that improper connection of the GT feeding could result in the resident not receiving the full prescribed amount of nutrition.