Failure to Cap G-Tube Feeding Tips When Not in Use
Penalty
Summary
The facility failed to ensure that the purple cone tip of the gastrostomy tube (g-tube) feeding apparatus was capped when not connected to the resident for two sampled residents. For both residents, observations revealed that the g-tube feeding tips were left uncapped and uncovered in their rooms. Record reviews indicated that both residents had orders for continuous tube feeding and care plans specifying the prevention of tube feeding-related infections. The manufacturer's guidelines for the feeding equipment directed that the connector cap should be replaced when not in use. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the g-tube tips should be capped to prevent contamination, as outlined in the manufacturer's instructions, although this requirement was not included in the facility's policy and procedure. Both residents involved had significant medical conditions, including respiratory failure, ventilator dependence, dementia, hypertension, and dysphagia, and were dependent on staff for personal care and nutrition via g-tube. The failure to cap the g-tube tips was observed directly and acknowledged by facility staff as inconsistent with manufacturer guidelines.