Failure to Ensure CNA Competency in Bed Bath Care for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in providing care for a resident with a PEG tube, specifically during bed baths. One nurse aide, while providing a bed bath and dressing the resident, accidentally dislodged the resident's PEG tube. The resident, who was completely dependent on caregivers for bathing and had multiple complex medical conditions including intractable epilepsy, aphasia, dysphasia, and required gastronomy feeding, was subsequently transferred to the hospital for tube replacement. The care plan for the resident did not include instructions for providing bed baths in the presence of a PEG tube. Interviews with staff revealed that the nurse aide involved had only received general bed bath training during CNA school and had not received any specific training or competency assessment on caring for residents with PEG tubes at the facility. Other CNAs also reported not being checked off on providing bed baths and relied on common sense or asking nurses if they had questions. There was no documentation of in-services or competency assessments related to bed baths or PEG tube care in the staff files or facility records. Supervisory staff, including the LVN and DON, confirmed that there was no formalized training or assessment for CNAs regarding PEG tube care during bed baths. The DON was unaware of the incident and stated that any change of condition requiring hospitalization should have triggered reeducation, but this did not occur. The administrator acknowledged that while reeducation was provided after the event, CNAs were not assessed for competency in providing bed baths for residents with PEG tubes, and there was no documentation of initial check-offs for the involved CNA.