Failure to Ensure Proper Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to provide appropriate feeding tube care for one resident who was cognitively intact and had a history of cerebral infarction, dysphagia, severe protein-calorie malnutrition, and adult failure to thrive. The resident had a gastrostomy tube for artificial nutrition and hydration, with a care plan indicating the need for site care and water flushes as ordered. However, a review of physician orders revealed there were no orders for water flushes before and after medication administration, nor for gastrostomy site care. Documentation was also lacking regarding water flushes and insertion site dressing changes. During interviews, nursing staff confirmed that residents should have orders for both medication flushes and insertion site care. Facility policies required staff to follow protocols for flushing feeding tubes before and after feedings and medications, and to perform daily or as-needed gastrostomy site care per physician order and professional standards. Despite these policies, the required orders and documentation were not present for the resident in question, resulting in a deficiency related to feeding tube care.