Failure to Implement Physician-Ordered G-Tube Site Care
Penalty
Summary
The facility failed to ensure that interventions listed on the resident-centered comprehensive care plans were specific to the care and services implemented for two residents with gastrostomy tubes (G-tubes). For both residents, the care plans indicated that dressing changes and skin care at the G-tube site should be provided as ordered, but there were no corresponding physician orders detailing the required care, frequency, or instructions for these interventions. Licensed nurses and the Director of Sub-Acute Services confirmed during interviews and record reviews that the necessary treatment orders were missing from the residents' records, despite facility policy requiring daily treatment to the G-tube site. Both residents were admitted with diagnoses requiring attention to their G-tubes, and their care plans included interventions to monitor and care for the G-tube site. However, the lack of specific physician orders meant that the care plans could not be properly implemented. Staff acknowledged that this omission was inconsistent with facility policy and recognized the importance of having clear, physician-directed instructions for G-tube site care. The facility's policy and procedure for comprehensive care plans also required that interventions reflect professional standards of practice and be tailored to identified problem areas.