Failure to Provide Appropriate GJ Tube Care and Adhere to Physician Orders
Penalty
Summary
The facility failed to provide necessary enteral care and services to a resident with a GJ tube, resulting in the resident receiving enteral feeding through the incorrect port. Staff were unable to accurately identify the G and J ports of the GJ tube, and as a result, enteral feeding was administered through the G tube port instead of the J tube port as ordered by the physician. Additionally, medications were administered through the incorrect port, and staff did not notify the physician when they were unable to verify the correct ports. The staff also did not receive in-service training on the care and management of a resident with a GJ tube prior to being assigned to the resident. The resident in question had significant medical needs, including diabetes, gastroparesis, ventilator-dependent respiratory failure, and was dependent on staff for activities of daily living. The resident was admitted with a GJ tube, with physician orders specifying that enteral feeding should be administered through the J tube port and medications through the G tube port. Despite these orders, staff were unable to confirm the correct port for feeding and medication administration, and did not seek clarification from the physician or other clinical leaders. The ports on the GJ tube were not labeled, contributing to the confusion among staff. Furthermore, the facility failed to obtain a physician's order for the maintenance and discontinuation of the G tube drainage bag. The resident was admitted with a drainage bag attached to the G tube port, but there was no documentation of a physician's order for its use or discontinuation. These failures led to the resident's transfer to an acute care hospital for medical intervention after the J tube became clogged, and the resident experienced a critical drop in blood sugar level.