Failure to Follow Physician Orders and Provide Adequate G-Tube Management
Penalty
Summary
The facility failed to provide services that meet professional standards by not following physician orders and not ensuring adequate management of a resident's enteral gastrostomy tube (g-tube). The resident, who had a history of cerebral infarction, hemiplegia, aphasia, myocardial infarction, severe protein-calorie malnutrition, and was admitted with a g-tube, was supposed to receive continuous tube feeding and regular g-tube flushes as ordered by the physician. However, documentation showed that the prescribed tube feedings and water flushes were not consistently administered, and there were no orders or documentation for essential aspects of g-tube care such as residual checks, placement verification, or monitoring intake and output. The facility also lacked clear policies and procedures for these standard practices. Observations and interviews revealed that the resident's feeding pump frequently malfunctioned, resulting in incomplete delivery of nutrition, and staff did not consistently document the amount of feeding received or notify the physician when feedings were missed or incomplete. The resident was observed lying flat in bed while receiving tube feeding, contrary to the requirement for head-of-bed elevation to reduce aspiration risk. Staff interviews indicated a lack of awareness and adherence to standard practices, such as checking tube placement and residuals, and there was confusion about proper documentation and communication with the physician regarding feeding issues. Additionally, the facility failed to accurately monitor the resident's weight, as weights were recorded without accounting for the weight of the wheelchair cushion, leading to inaccurate assessments of the resident's nutritional status. Family members reported concerns about the resident's weight loss, lack of nutrition, and inadequate care, which were not thoroughly investigated by facility leadership. The Medical Director and facility administration were unaware of the ongoing issues with the resident's enteral feeding and weight loss, and there was no evidence that standard practices for enteral nutrition management were being followed or that staff were properly trained in these procedures.