Failure to Timely Address G-Tube Leakage and Notify Physician
Penalty
Summary
A resident with a gastrostomy tube (G-tube) experienced continuous leakage of tube feeding formula around the stoma site from January 2025 to the present. Observations and interviews revealed that the leakage was noted by nursing staff, with visible leaking through the G-tube dressing and increasing redness and size of the affected area. The resident, who had diagnoses including gastrostomy status, dysphagia, and tracheostomy, was totally dependent on staff for all activities of daily living and had severely impaired cognitive skills. Despite ongoing documentation of the leakage and skin changes in weekly assessments, there was a lack of timely follow-up and communication with the physician regarding the persistent issue. The care plan for the resident indicated that the physician should be notified if there was no progress in healing or signs of decline related to the G-tube site. However, staff interviews and record reviews confirmed that the leakage persisted for several months without adequate escalation or intervention. The Assistant Director of Nursing and other staff acknowledged that the evaluation and management of the G-tube site should have occurred earlier, and that licensed nurses should have reported abnormal changes to the physician as per facility policy. The resident was eventually transferred to a general acute care hospital for evaluation and management of the leaking G-tube.