Failure to Provide Proper G-Tube Care and Maintain Closed Feeding Systems
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications related to enteral feeding for four residents with gastrostomy tubes. Specifically, the facility did not ensure that gastrostomy tube (G-tube) dressings were changed and dated as ordered for three residents. In one case, a resident's family reported finding the G-tube dressing soiled with a foul odor and the feeding tube end uncapped and dirty over multiple days. Documentation in the Medication Administration Record (MAR) indicated that dressing changes were marked as completed, but observations and family-provided photos contradicted this, showing undated and soiled dressings. Interviews with nursing staff revealed uncertainty about when dressings were last changed and acknowledged that not dating dressings could lead to confusion about care provided. Additionally, the facility failed to ensure that formula tubing was sealed with a cap during downtime for two residents. Observations showed that the feeding tube ends were left uncapped and hanging from IV poles when not in use, creating an open system. Staff interviews confirmed that the expectation was to use the clear plastic cap provided with the formula bags to close the line when not connected to the resident, but this was not consistently done. Some staff were unaware of the importance of capping the tubing or did not consider it within their responsibilities. The facility's policies required daily dressing changes, proper documentation, and infection control practices to prevent contamination and infection. However, interviews with the infection control preventionist, DON, and administrator revealed a lack of awareness and oversight regarding missed dressing changes and undated dressings. The failure to follow established protocols for G-tube care and formula tubing management was observed and confirmed through interviews, record reviews, and photographic evidence.