Failure to Update Care Plan for Gastrostomy Tube Dislodgement
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of intractable epilepsy, malnutrition, aphasia, dysphasia, intellectual disability, and anoxic brain damage, who was dependent on a gastrostomy tube for nutrition. The care plan did not include instructions or interventions for managing situations when the resident’s gastrointestinal tube became dislodged, despite multiple documented incidents of tube dislodgement that required medical intervention or hospitalization. The care plan only referenced checking tube placement and gastric contents, omitting guidance for tube removal or replacement. Record reviews revealed that the resident’s PEG tube had become dislodged on several occasions, leading to physician visits and hospital transfers for tube replacement. Staff interviews confirmed that there was no specific training or education provided to CNAs regarding the handling of PEG tubes during care, nor were there updates to the care plan following these incidents. The CNA involved in one incident reported not receiving additional training after the event, and both the CNA and LVN stated that having clear care plan instructions would have been beneficial for staff unfamiliar with the resident’s needs. Administrative staff, including the DON and ADM, acknowledged that care plans should be updated to reflect significant changes or incidents, such as hospitalization due to device dislodgement. However, the care plan was not revised to address the management of the resident’s PEG tube dislodgement, and the facility’s care plan policy was not provided upon request. This lack of comprehensive care planning placed the resident at risk for complications related to indwelling devices.