Failure to Provide Consistent PEG Tube Care and Documentation
Penalty
Summary
The facility failed to ensure consistent and appropriate care for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who was dependent on staff for all activities of daily living and had diagnoses including cerebral infarction and multiple myeloma, experienced a clogged PEG tube, which was unsuccessfully addressed by nursing staff and ultimately required hospital intervention. Observations revealed soiled towels with large amounts of yellow and brown drainage left on and under the resident, and staff present during the observation were unable to explain the source of the drainage or why the towels had not been changed. There was no documentation in the medical record of abnormal drainage or incidents that morning. Further review of the resident's medical record showed a lack of consistent documentation regarding PEG care, and no current physician orders for PEG care were found. Previous orders for PEG site management had been discontinued without a documented date, and staff interviews confirmed uncertainty about the status of PEG care orders. The nurse assigned to the resident on the day of observation had not documented any PEG care or the events that occurred, despite being aware of the PEG tube leaking and the resident being sent to the hospital. These findings indicate a failure to provide and document necessary PEG tube care as required.