Failure to Assess and Supervise Resident with G-Tube Leading to Unsafe Self-Administration and Ingestion Behaviors
Penalty
Summary
The facility failed to assess a resident with vascular dementia, dysphagia, and NPO status for self-administration of enteral feedings and did not implement effective interventions after repeated observations of unsafe behaviors. The resident was observed multiple times by staff and surveyors self-administering tube feedings, using unidentified liquids in her gastrostomy tube, rummaging through trash for food and liquids, chewing and spitting out food, obtaining food as bingo prizes, and disconnecting herself from her g-tube pump during continuous feedings. Despite these behaviors, there was no documented assessment or physician order for self-administration of tube feedings, and the care plan interventions were limited to education and reminders, which were inconsistently provided and documented. Staff interviews revealed that the resident frequently disconnected her tube feeding, used items from the trash, and attempted to self-administer both water and tube feeding formula, sometimes using bottles she had taken from the trash or her room. Several staff members, including nurses and the NP, were aware of these behaviors but did not consistently communicate them to the physician, Registered Dietician, or other relevant team members. The Medical Director and Psychiatric NP were not made aware of the full extent of the resident's behaviors, and the Registered Dietician was not informed about deviations in the resident's tube feeding regimen. The Activities Director was also unaware of the resident's NPO status and provided food prizes for bingo, despite the resident's inability to swallow. Observations and record reviews indicated a lack of effective supervision and monitoring, as the resident was able to access and use potentially contaminated items for her tube feedings and was not prevented from obtaining or attempting to consume food and liquids orally. Documentation was inconsistent, and there was no system in place to ensure that all staff, including agency staff, were aware of and followed the resident's care plan. The facility's failure to assess the resident's capacity for self-administration and to implement and communicate effective interventions resulted in ongoing unsafe behaviors and placed the resident at risk.