Failure to Provide Timely Maintenance Care for PEG Tube
Penalty
Summary
Facility staff failed to provide appropriate maintenance care for a resident's percutaneous endoscopic gastrostomy (PEG) tube. Upon admission, the resident had a PEG tube in place, but there were no orders for monitoring or flushing the tube until several days after admission. The medical record review revealed that orders for flushing the PEG tube with water, inspecting the site for signs of infection, and completing tube site care were not entered until nearly a week after the resident's admission. There was no documentation of the tube being flushed or monitored prior to these orders being added to the Medication Administration Record. Interviews with facility staff, including the unit manager and the DON, confirmed that they would have expected PEG tube care orders, including maintenance flushing and site monitoring, to be in place upon admission. The resident was able to eat and drink by mouth, and the PEG tube was not being used for feeding, but staff acknowledged that maintenance flushes should still have been performed. The lack of timely orders and documentation resulted in a failure to ensure proper maintenance care for the resident's PEG tube.