Failure to Provide Proper PEG Site Care and Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to ensure proper care and monitoring of enteral feeding and gastrostomy sites for two residents. One resident, who had recently received a PEG tube prior to admission, reported that no site care had been performed and described the site as draining and unclean. Observations confirmed an old, discolored dressing with green and black purulent drainage and a foul odor, with the dressing dated several days prior. Record review and staff interviews revealed that there were no physician orders for PEG site care or monitoring for approximately 21 days after admission, and the site had not been assessed or the dressing changed as required. The resident continued to receive bolus feedings during this period, and staff confirmed the lack of orders and monitoring. Another resident receiving tube feedings was observed with a feeding bag that was not properly labeled. The bag only included the resident's last name and date, but did not indicate the time it was hung, the type of enteral feeding, or the rate. Staff interviews confirmed that the label was incomplete and did not meet facility policy, which requires the full name, rate, time and date hung, and type of feeding to be included. The family member present was also unaware of the type of enteral feeding being administered. Both residents had relevant medical histories, including recent surgical aftercare and gastrostomy status. The deficiencies were identified through observation, interview, and record review, and were confirmed by staff and facility leadership. The lack of timely physician orders, monitoring, and proper labeling of enteral feeding equipment directly contributed to the deficiencies cited.