Failure to Prevent G-Tube Dislodgement in Residents with Behavioral Risks
Penalty
Summary
The facility failed to ensure that residents receiving enteral nutrition via feeding tubes received appropriate treatment and services to prevent complications related to tube dislodgement. Two residents with a history of restlessness and behaviors such as pulling on or removing their G-tubes did not have adequate interventions in place, such as abdominal binders, to prevent repeated dislodgement of their feeding tubes. This resulted in multiple incidents where the residents pulled out their G-tubes, requiring hospitalization for tube replacement, and in one case, an IV pole fell on a resident's head during an episode of pulling on the tube, causing injury. For one resident, medical records indicated a history of severe cognitive impairment, dependence on staff for all care, and ongoing behaviors including agitation and attempts to pull out her G-tube. Despite these documented behaviors and multiple incidents of tube dislodgement, the resident's care plan did not address the risk of G-tube removal or include interventions such as an abdominal binder. Staff interviews confirmed that the resident was known to be restless and to pull on her tube, but no consistent preventive measures were implemented prior to the incidents. A second resident with similar cognitive and behavioral issues also experienced multiple episodes of G-tube dislodgement, leading to repeated hospitalizations. The care plan and physician orders for this resident did not include the use of an abdominal binder or other interventions to address the risk of tube removal until after several incidents had already occurred. Staff interviews and record reviews revealed a lack of communication and documentation regarding these behaviors, and the care plans were not updated to reflect the residents' needs for preventive interventions until after the deficiencies were identified by surveyors.