Failure to Obtain Physician Orders for G-Tube Site Care
Penalty
Summary
The facility failed to ensure that physician orders were in place to direct the care of gastrostomy tube (G-tube) sites for two residents who required such care. For both residents, clinical record reviews and interviews with licensed nursing staff confirmed that there were no active physician treatment orders specifying the necessary care for the G-tube sites. Staff acknowledged that facility policy required daily treatment of G-tube sites, and the absence of these orders meant that the prescribed care was not documented or provided as required. Further review of treatment administration records showed no evidence that one resident received any G-tube site care upon readmission, and the other resident lacked orders for dressing changes or site cleaning over a specified period. The Director of Sub-Acute Services confirmed that it was expected for residents with G-tubes to have physician orders detailing treatment instructions. The facility's own policy emphasized the importance of keeping the skin around the G-tube exit site clean, dry, and lubricated, but this standard was not met due to the missing orders.