Failure to Assess and Monitor Feeding Tube Site After Readmission
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and care of a resident's gastric tube following readmission. The resident, who had multiple complex medical conditions including chronic respiratory failure, end stage renal disease, and a history of gastrostomy infection, was readmitted after a hospital stay. Upon readmission, the required assessment was not completed in a timely manner, with the gastrointestinal section, including information on the gastric tube, left incomplete for several days. There was no evidence in the medical record of any orders or documentation for feeding tube site care, monitoring, or assessment during this period. Observations and interviews confirmed that the resident's J-tube site was not being properly managed. The site was observed to have dark brown drainage with granules, and the resident reported that the site had been in that condition since returning from the hospital. Staff interviews revealed that no orders for J-tube site care were present until three days after readmission, and that routine care for the site should have been in place. The facility's own policies required daily monitoring and documentation of enteral tube sites, as well as prompt initiation of admission and readmission assessments, but these were not followed. Multiple staff members, including the DON, ADON, and LPNs, confirmed the lack of timely assessment and absence of orders for J-tube care in the days following the resident's readmission. The deficiency was substantiated by review of the medical record, which showed no documentation of site care or monitoring until several days after the resident's return. The failure to promptly assess and provide care for the feeding tube site was in direct violation of facility policy and physician expectations.