Lack of Physician Orders for G-Tube Site Care
Penalty
Summary
A deficiency was identified when a resident with a G-tube, who had diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, did not have physician orders for G-tube site care during the review period. The resident's care plan indicated a need for tube feeding and specified that local care to the G-tube site should be provided as ordered, with monitoring for signs and symptoms of infection. However, a review of the physician's orders for the relevant period showed no orders for G-tube site care. During interviews, an LPN confirmed that there were previously orders for G-tube site care but none were currently present in the system, despite the importance of cleaning the site to prevent infection. The DON also stated that standard orders for residents with G-tubes should include head of bed elevation, G-tube flushing, and site care, and acknowledged that the absence of these orders was an oversight. Facility policy requires physician orders for essential care at admission, but this was not followed in this case.