Failure to Revise Care Plan After Repeated PEG Tube Dislodgement
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident following multiple incidents of PEG tube dislodgement. According to the facility's policy, care plans must be updated as residents' conditions change, including after hospital readmissions. Medical record review showed that the resident, who had diagnoses including hypertensive heart disease, atrial fibrillation, diabetes, dysphagia, and a PEG tube, was transferred to the emergency room several times due to the PEG tube being dislodged. Despite these incidents and documentation of the resident pulling out the tube, the care plan was not updated to address the resident's manipulation of the PEG tube or to include specific interventions for this behavior. Observations of the resident showed no manipulation of the PEG tube at the time, but interviews with staff revealed that a velcro abdominal binder was used to help maintain the PEG tube position when the resident was restless. Staff reported that the resident sometimes pulled at the binder, which reduced its effectiveness in covering the tube. The Director of Nursing and the MDS Nurse both confirmed that the care plan had not been revised to reflect the resident's behavior of manipulating the PEG tube or the interventions being used.