Failure to Administer Prescribed Water Flushes via PEG Tube
Penalty
Fine: $95,118
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
Facility staff failed to provide a resident with water flushes via a gastrostomy tube as prescribed. The resident, who had a history of dysphagia following cerebral infarction and was dependent on tube feeding, had a physician's order for hydration water flushes of 300 milliliters every four hours. However, during an observation, it was found that the feeding pump was set to deliver water flushes every six hours instead of the ordered four-hour interval. The assigned LPN confirmed that the pump setting was incorrect and admitted not checking the tube feeding settings at the start of the shift. The resident was noted to have severely impaired cognitive status and was dependent on staff for tube feeding and hydration.