F0693

D

Failure to Provide Ordered G-Tube Site Care and Maintain Clean, Dressed Stoma

Chicago Ridge, Illinois Survey Completed on 01-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own enteral tube feeding care policy and physician orders for a male resident with a gastrostomy tube (g-tube). The resident, admitted with multiple diagnoses including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, bipolar disorder, and documented gastrostomy status, had a care plan dated 11/6/25 indicating he was receiving gastric tube feeding due to atresia of the esophagus with tracheoesophageal fistula and was at risk for infections, fluid overload, dehydration, and aspiration pneumonia. The care plan included an intervention to check the g-tube site for signs and symptoms of infection and notify the physician. An order dated 1/05/2026 at 1:30 p.m. directed staff to cleanse the enteral tube feeding site with normal saline and apply a dry dressing, and the facility’s policy required the g-tube stoma site to be cleansed and covered with dry gauze daily.

Record review showed that this g-tube site care order was not transcribed onto the scheduled area of the Treatment Administration Record, and there was no documentation that g-tube site care was performed from 1/5/2026 through 1/16/2026. Nursing progress notes for 1/5/2026 also contained no documentation of g-tube care. During an observation on 1/16/2026 at 1:18 p.m., the resident reported that staff were supposed to clean his g-tube site and apply a dressing but did not do so consistently, stating that sometimes they cleaned it and sometimes they did not. He reported that a nurse removed the gauze the previous day and did not clean the site or replace the dressing. The surveyor observed a large amount of brownish-blackish crust encircling the g-tube stoma and noted that there was no dressing in place.

When the ADON assessed the g-tube site at 1:36 p.m. on the same day, she stated that the site should be covered and appeared to need cleaning due to crust build-up; the resident winced in pain and stated the area was sore. After the ADON left, the resident stated that because staff did not clean his g-tube site, he would clean it himself with alcohol and that removal of the gauze the previous day had hurt. Later, an agency LPN entered the room and stated she had not changed the dressing because it was changed on night shift, but acknowledged that the g-tube was supposed to be cleansed with normal saline and gauze applied, and that the site had crust around it. The DON stated that nurses should be changing the g-tube dressing daily, ensuring the area is cleaned, and documenting it on the TAR or MAR, consistent with the facility’s enteral tube feeding care policy and the floor nurse job descriptions for LPNs and RNs, which require administering and supervising prescribed treatments such as tube care.