Failure to Provide Ordered PEG Tube Site Care and Accurate Documentation
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services as ordered for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Facility policy required daily dressing changes and site care to promote cleanliness and prevent irritation, breakdown, and infection. The physician's order specified that the PEG tube drain sponge should be changed daily, and the area cleansed and dried before applying a new dressing. The resident, who had diagnoses including protein-calorie malnutrition, aphasia, and dementia, was assessed as having a PEG tube and required tube feeding due to dysphagia and inability to eat. Medical record review indicated that the Medication Administration Record (MAR) documented daily dressing changes for the entire month. However, on direct observation, the dressing on the PEG site was dated four days prior, indicating it had not been changed as ordered. Interviews with the RN and DON confirmed that the dressing should have been changed daily and that the MAR documentation was inaccurate, as it did not reflect the actual care provided.