Failure to Develop Comprehensive Care Plan for G-Tube Dislodgement
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident with a history of gastrostomy tube (G-tube) dislodgement. Despite multiple documented incidents of the resident pulling or dislodging her G-tube, there was no care plan addressing this issue from the time of admission through several months of care. The resident had diagnoses including type 2 diabetes mellitus, gastrostomy malfunction, and unspecified dementia, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. Multiple SBAR documents and staff interviews confirmed repeated episodes of G-tube dislodgement and behaviors such as pulling at the tube or linens, especially during care activities like dressing changes. Staff interviews revealed that the resident had a strong grip and would often grab her G-tube, requiring additional staff assistance during care to prevent dislodgement. Despite these ongoing issues, several staff members, including licensed nurses and the MDS nurse, were unaware of any care plan specifically addressing G-tube dislodgement or the resident's behavior of pulling at the tube. The care plan for G-tube dislodgement was not created until months after the initial incidents, and even then, it did not include interventions tailored to the resident's specific behaviors. Record review and interviews with the Registered Nurse Supervisor confirmed that no interdisciplinary team (IDT) meetings had been conducted to address the resident's frequent G-tube dislodgement, and the care plan lacked resident-centered interventions. The facility's own policy required comprehensive, individualized care plans to be developed and updated as needed, but this was not followed in the resident's case, resulting in inconsistent implementation of care.