Failure to Ensure Proper G-Tube Care and Placement Verification
Penalty
Summary
A resident with a history of stroke, hemiplegia, dysphagia, and MRSA infection was admitted with a recently placed gastrostomy tube (G-tube) for enteral feeding. The care plan and baseline care plan indicated the need for continuous feeding via G-tube and required verification of tube placement prior to medication administration and per facility protocol. However, documentation confirming the placement of the feeding tube was missing for several days prior to the resident's hospitalization. On multiple occasions, the resident was observed to have issues with the G-tube, including leakage around the insertion site, pain, and grimacing during care. Despite these symptoms, there was no documented evidence that staff verified the tube's placement as required by facility policy. Interviews with staff confirmed that placement checks should have been performed and documented, but the Medication Administration Record and Treatment Administration Record lacked this documentation for the relevant dates. It was also noted that the nurse responsible for care on the days in question had not signed the facility's G-tube training and policy in-service. The resident ultimately experienced a dislodged G-tube, leading to aspiration pneumonia, sepsis, and the need for hospitalization. Hospital records indicated that the G-tube had become malpositioned, resulting in feeding into the chest wall and abdomen, and the resident could not have a new G-tube placed for approximately six weeks due to infection. The facility's failure to ensure necessary interventions and proper documentation contributed to the resident's adverse outcome.