Failure to Follow Physician Orders for Abdominal Binder Use with G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a gastrostomy tube received care in accordance with professional standards and physician orders regarding the use of an abdominal binder. The resident, admitted with a diagnosis including a gastrostomy tube and assessed as having severe cognitive impairment with dependence on staff for dressing, had physician orders dated 9/4/2025 to encourage use of an abdominal binder at all times on every shift, and a subsequent order dated 1/7/2026 specifying that the resident was to wear the abdominal binder and may remove it only during activities of daily living care or showering. A community complaint alleged that the resident frequently damaged or pulled out the G-tube and that the facility did not implement proper precautions, including use of an abdominal binder, to prevent the resident from pulling out the tube. During surveyor observation, the resident was seen in bed without the abdominal binder in place under the shirt, and the binder was found on a shelf across the room from the resident’s bed. In the presence of the surveyor, an LPN acknowledged that the resident was not wearing the abdominal binder and admitted she had failed to assist the resident to put it on that morning. In a subsequent interview, the Director of Nursing Services stated that she would have expected the abdominal binder to be in place on the resident. These observations and interviews demonstrated that staff did not follow the physician’s orders for continuous use of the abdominal binder, except during specified care activities, resulting in the cited deficiency.
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