Failure to Provide and Document Daily G-Tube Stoma Dressing Change
Penalty
Summary
A deficiency occurred when a treatment nurse failed to provide a daily gastrostomy tube (g-tube) stoma dressing change for a resident as ordered by the physician. The resident, who had a history of stroke and dysphagia and was cognitively intact, reported that the dressing change was not performed on the previous day. During observation, the nurse removed a dressing with a moderate amount of dried brown drainage and noted redness at the stoma site, which was also tender to touch. The nurse was unable to determine if the drainage was from the g-tube nutrition or the site itself and acknowledged the redness could be due to irritation from the drainage. Record review revealed that the treatment administration record (TAR) had been initialed by the nurse, indicating the dressing change was completed, even though the treatment was not provided. The nurse admitted to not performing the dressing change due to being occupied with rounds with the wound doctor and also failed to endorse the missed treatment to the next shift or notify the charge nurse, contrary to facility policy. The care plan for the resident required local care to the g-tube site as ordered and monitoring for infection, and facility policy mandated that treatments be provided as ordered and documented accurately.