Failure to Develop and Implement Care Plan for G-Tube
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was admitted with diagnoses including dysphagia and partial paralysis to the left side, and who had a G-tube in place. Upon review of the resident's admission record, order summary report, and care plan documentation, it was found that there was no current physician's order or care plan addressing the G-tube, despite its presence. The resident expressed a desire to have the G-tube removed, and during multiple interviews and record reviews with facility staff, it was acknowledged that the necessary documentation and care planning for the G-tube were missing. Further interviews with a licensed nurse, nurse practitioner, and the director of nursing confirmed that there was no current order for the G-tube and no care plan developed, revised, or resolved for its care and treatment. The facility's own policy requires a comprehensive care plan that includes measurable objectives to meet the resident's needs, including medical devices. The lack of a care plan for the G-tube meant the resident's specific needs related to this device were not formally addressed.