Failure to Document PEG Tube Dislodgement and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident who was dependent on a percutaneous endoscopic gastrostomy (PEG) tube for nutrition due to dysphagia and cognitive communication deficit. The resident’s face sheet and care plan documented gastrostomy status and the need for tube feeding. Emergency department records show that the resident arrived with a dislodged feeding tube and had a temporary tube placed, with an outpatient procedure planned to replace the PEG. However, the facility’s medical record contained no documentation of the PEG tube being pulled out, no description of the incident, and no indication that the resident left the facility for emergency care. Staff interviews confirmed that the event occurred and that required documentation was omitted. A CNA reported finding the resident in bed with the feeding tube on the floor, minimal blood at the site, and the resident in no apparent distress; she took vital signs, which were normal, and prepared the resident for transport to the emergency room, reporting the incident to an RN. The RN stated she was notified that the PEG tube had been removed, directed the CNA to obtain vital signs, and notified the on-call manager and physician before sending the resident to the emergency room, but acknowledged that due to multiple simultaneous emergencies it would not be surprising if nothing was documented. An LPN stated there should have been an order for hospital transfer, progress notes detailing the event, and documentation of family and physician notification. The DON stated nurses should document why and when a resident leaves, with whom, and in what condition. This lack of documentation was inconsistent with the facility’s policy requiring complete, accurate, and timely documentation of each resident’s experiences and care, to be completed no later than the end of the shift in which the care occurred.
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