Incomplete Documentation of Physician's Order for G-Tube Flush
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding physician's orders for a gastrostomy tube (G-tube) flush for a resident with significant medical needs. Specifically, the clinical record for a resident with spastic quadriplegic cerebral palsy, intellectual disabilities, and diabetes did not contain a physician's order for a one-time G-tube flush using a 50/50 mixture of hydrogen peroxide and hot water, which was performed to clear a clogged tube. Nurse's notes documented that the flush was completed as instructed, but there was no corresponding physician's order in the resident's clinical record for this intervention on the date it was performed. During interviews, the Medical Director confirmed that a verbal order for the G-tube flush had been given and that the practice was considered safe. However, the Director of Nursing acknowledged that the resident's clinical record lacked evidence of the physician's order for the procedure. This deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was determined that the facility did not adhere to its own policy requiring all telephone orders to be recorded in the resident's clinical record.