Failure to Transcribe and Complete Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to ensure that physician orders for PEG tube care were transcribed and completed for two residents with PEG tubes. For one resident, observation revealed that the PEG site had no gauze, dark residue around the insertion site, and red droplets on the clamp. There were no physician orders in place for PEG tube care for this resident, who was blind, had moderately impaired cognition, and was dependent on staff for all activities of daily living. The Director of Nursing (DON) confirmed that the site was not clean and that daily care should have been provided, especially in the presence of drainage. For another resident, the PEG tube site was observed with old gauze labeled with a previous date and shift, and dark residue was present under the gauze at the site entrance. Similarly, there were no physician orders for PEG tube care for this resident, who also had moderately impaired cognition, chronic kidney disease stage 5, and was dependent on staff for all activities of daily living. An LPN confirmed that care was documented as completed, but new gauze was not available, so the old gauze was left in place.