Deficient Care in Tube Feeding Management, Change in Condition Monitoring, and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with a history of oropharyngeal cancer and severe dysphagia, there were multiple failures in the management of tube feeding and NPO status. Despite physician orders for enteral feeding via PEG tube and NPO status, the resident consistently refused tube feedings, medications, and flushes, instead consuming enteral nutrition orally and other foods. Staff provided bottles of enteral feeding for the resident to consume orally without a corresponding physician order, and there was no evidence of a signed medical waiver. The resident's refusals and actual intake were inconsistently documented, and weekly weights ordered by the physician were not completed or tracked. The resident's room contained a refrigerator with expired and inappropriate food items, and the PEG tube site was observed to be red, inflamed, and without proper dressing, indicating a lack of monitoring and care. Another resident returned from the hospital with a diagnosis of aggressive behaviors, but there was no documentation of a progress note or change in condition assessment prior to the hospital discharge. Facility leadership confirmed that such documentation should have been completed according to policy, but review of the medical record showed no evidence of this. This lack of documentation failed to ensure proper monitoring and continuity of care during a significant change in the resident's condition. A third resident with a history of convulsions, stroke, and traumatic brain injury experienced a possible seizure and hypotension, as reported by the resident's son and documented by an LPN. However, the LPN later admitted she had not directly observed the seizure and had documented based on the son's report. There was no progress note authored prior to the resident's hospital admission, and blood pressure readings were significantly low. Facility policy required detailed observation and documentation of changes in condition, which was not followed. These failures in documentation, assessment, and adherence to physician orders resulted in deficiencies in the quality of care and treatment provided to the residents.