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F0656
B

Failure to Develop Care Plan for EBP Status with Gastrostomy Tube

Garden Grove, California Survey Completed on 07-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to develop a care plan problem for a resident who was placed on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube (GT). The facility's policy requires a comprehensive, resident-centered care plan with measurable objectives and timeframes for each resident, based on their comprehensive assessment. Medical record review showed that the resident was readmitted to the facility and had physician orders to check GT placement and patency every shift, as well as to implement EBP every shift due to the GT. However, review of the resident's care plan did not show any care plan developed to address the EBP status as ordered by the physician. During interviews, the RN confirmed that no care plan was developed for the resident's EBP related to the GT, despite the physician's order and the resident having the GT since readmission. The RN explained that the admitting nurse initiates the baseline care plan, and other RNs or MDS staff add care plans as needed. The DON also confirmed that the care plan should have been initiated after receiving the physician's order for EBP and that MDS staff are responsible for reviewing care plans for completion. Both the DON and Administrator acknowledged the findings.

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