Unlicensed Staff Adjusted G-Tube Pumps Without Proper Training or Authorization
Penalty
Summary
The facility failed to ensure that only licensed and trained nursing staff adjusted gastrostomy tube (G-tube) pumps for a resident who was dependent on enteral feeding due to multiple medical conditions, including hemiplegia, aphasia, bed confinement, moderate protein-calorie malnutrition, and a history of intracerebral hemorrhage. Record reviews and staff interviews revealed that unlicensed staff, specifically CNAs, were placing G-tube pumps on hold during routine care such as changing and repositioning the resident. These CNAs reported that they had learned how to pause the pumps by observing nurses, but did not have formal training or knowledge of the risks involved. Multiple licensed nurses confirmed that only licensed staff should handle G-tube pumps, but acknowledged that CNAs commonly paused the pumps and that there was no clear policy specifying who was responsible for this task. The deficiency was further evidenced by the lack of a specific facility policy outlining which staff members were authorized to operate G-tube pumps. The Regional Nurse confirmed that only licensed staff were expected to handle the pumps, but also acknowledged the absence of a written policy. Documentation showed that the issue came to light after a CNA reported a resident vomiting, and it was discovered that CNAs had been pausing the G-tube pump without proper authorization or training. The resident involved was unable to communicate due to cognitive and physical impairments.