Failure to Prevent Mold Formation in Feeding Tube
Penalty
Summary
The facility failed to provide proper care for a resident's feeding tube, resulting in mold formation within the tube. The resident, who had multiple complex medical diagnoses including cerebral infarction, diabetes, hemiplegia, anoxic brain damage, and dysphagia, was dependent on staff for all activities of daily living and had a PEG tube for nutrition and hydration. Physician orders required regular hydration flushes every four hours, daily cleansing of the PEG tube site, and routine tube feedings. Despite these orders, the internal tubing developed brownish discoloration and mold, which was not identified or reported by staff in a timely manner. Staff interviews revealed that certified nursing assistants had noticed the discoloration but did not recognize it as mold, and licensed nurses did not observe or report the issue during routine care. The facility's policy required licensed nurses to provide routine care to maintain tube patency and skin integrity, but this was not followed, as evidenced by the presence of mold in the tube. The resident was eventually sent to the hospital for evaluation and replacement of the PEG tube after the mold was discovered.