Failure to Maintain G-Tube Cleanliness and Follow Flushing Orders
Penalty
Summary
The facility failed to provide necessary care and services related to G-tube management for three residents receiving enteral feeding. For two residents, observations revealed that the medication ports on their G-tube tubing contained a black substance, indicating that the ports were not kept clean or patent as required. Staff interviews confirmed that the tubing should have been changed or cleaned, and the presence of the black substance was verified by both CNAs and LVNs during the observations. Medical record reviews supported that these residents had orders related to G-tube care, but the observed conditions did not meet those standards. For another resident, the facility did not follow physician orders to flush the enteral feeding tube with 30 ml of water before and after medication administration. Medical record reviews showed a lack of documentation that the required flushes were performed over a specified period, despite clear physician orders. The DON acknowledged that the licensed nurse should have documented the flushes and followed the physician's orders. These failures were identified through observation, interview, and review of medical records and facility policies.