Failure to Perform and Accurately Document Daily Feeding Tube Dressing Changes
Penalty
Summary
A resident with functional quadriplegia, ventilator dependence, and heart failure had an active physician order, dated 12/4/24, for cleansing the enteral tube feeding site with normal saline and applying a dry dressing every night shift. During surveyor observation, the resident was noted in bed with a foul odor that was not consistent with stool. Later that morning, during incontinence care, staff exposed the resident’s abdominal tube feeding site and observed a split 4x4 gauze dressing with dried black drainage near the tube and a pronounced odor. The dressing was dated 12/29, indicating it had not been changed for approximately nine days despite the daily dressing change order and the facility’s policy requiring daily cleansing and dry gauze coverage of the enteral tube site. The resident’s nurse confirmed that the date on the dressing reflected the last time it was changed and acknowledged that the dressing should have been changed before the day of the survey, stating that tube feeding dressings are typically changed daily on the night shift. When the dressing was removed, the skin underneath was described as reddened, inflamed, and appearing raw. Review of the December and January Treatment Administration Records showed that night shift staff had documented completion of the tube feeding dressing changes on multiple days after 12/29, even though the physical condition and date of the dressing indicated those changes had not been performed. The DON stated that feeding tube dressings should be changed daily on the night shift to prevent infections and that staff should not document dressing changes unless they are actually completed.
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