Failure to Follow Care Plans for PEG Site Care, Safe Transfers, and Call Light Accessibility
Penalty
Summary
Staff failed to follow the comprehensive care plan for three residents, resulting in deficiencies in care. For one resident with a recent PEG tube placement, there was no documented PEG site care order until several weeks after admission, despite the care plan indicating the need for site care and monitoring for infection. The resident reported that no one had performed PEG site care, and observations revealed an old, discolored dressing with purulent, foul-smelling drainage and signs of infection at the site. Another resident, who required staff assistance with transfers and had a care plan specifying the use of a stand-assist mechanical lift, was manually transferred by two CNAs without the lift. This manual transfer resulted in the resident's foot becoming caught under a wheelchair, leading to a right ankle sprain. The resident confirmed that the transfer was not performed according to the care plan and that the injury affected her ability to participate in therapy. A third resident, who was at risk for falls, had a care plan intervention requiring the call light to be within reach. During observation, the call light was found wrapped around a light fixture and not accessible to the resident, who reported being unable to get help when needed. Staff confirmed that ensuring the call light was within reach was their responsibility, but this was not done at the time of observation.