Failure to Prevent and Investigate Repeated Gastrostomy Tube Dislodgement
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received appropriate care and services to prevent complications related to repeated dislodgement of the GT. The resident experienced multiple incidents of GT dislodgement on at least seven separate occasions, each requiring medical intervention and replacement of the tube. Despite these repeated events, the facility did not conduct assessments or document investigations into the possible causes of the dislodgements, except for one incident. There was also no evidence of updated or modified interventions to prevent further occurrences, and no interdisciplinary team (IDT) meetings were held to address the frequent GT dislodgement. Staff interviews revealed that the primary intervention implemented was the use of an abdominal binder to prevent the resident from pulling at the GT, along with a sign instructing staff to keep the resident's right arm outside the sheets. However, staff also reported that the GT had been pulled out by staff during repositioning and that there were lapses in supervision, such as leaving the resident alone without the abdominal binder during shower preparation. Additionally, the shower team was not consistently informed about high-risk residents prior to showers. The facility's lack of investigation, documentation, and updated interventions contributed to the ongoing issue of GT dislodgement for this resident.