Failure to Develop and Implement Individualized Care Plan for GT Dislodgement
Penalty
Summary
The facility failed to develop and implement an individualized care plan to address and prevent the repeated dislodgement of a resident's gastrostomy tube (GT). Despite multiple documented incidents where the resident's GT became dislodged, the care plan did not include a specific problem statement or interventions aimed at minimizing the risk of further dislodgement. The facility's policy requires that care plans reflect current standards of practice, be person-centered, and be updated as residents' conditions change, but this was not followed in the case of this resident. Medical record review showed several change of condition assessments related to the dislodged GT over a period of time, yet the care plan was not revised to address this recurring issue. During an interview and concurrent record review, the Assistant Director of Nursing (ADON) confirmed that a care plan to prevent GT dislodgement should have been developed for the resident, but was not present. This resulted in the resident not receiving appropriate, consistent, and individualized care to address the risk of GT dislodgement.