F0693

J

Failure to Provide Ordered PEG Tube Care Leading to Infection and Sepsis

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide physician-ordered gastrostomy (G-tube/PEG) care, including cleansing, laboratory monitoring, flushes, residual checks, and tube insertion site assessments, for a resident receiving nutritional support via an internal PEG tube. The facility’s own Gastrostomy Tube – Feeding and Care policy required measurement of gastric residuals as ordered, observation for nausea, vomiting, diarrhea, abdominal distention or cramping, and immediate reporting and treatment of skin irritation or infection at the stoma site, including cleansing with soap and water or antiseptic and thorough drying. The resident’s care plan documented dependence on tube feeding and water flushes, the need to check tube placement and gastric residuals per facility protocol, and to obtain and monitor labs as ordered and report results to the physician.

The resident’s physician orders included G-tube site care to cleanse and apply split gauze every shift for infection control and to check residuals before medications and feedings, with instructions to hold feeding and medications and notify the physician if residuals were greater than 100 ml. This residual order was not initiated until five days after admission. Treatment Administration Records showed that G-tube site cleaning and gauze changes were missed on multiple occasions across several months, including missed cares on specific shifts and repeated failures to perform scheduled residual monitoring prior to feedings and medication administration. Additional orders to cleanse the G-tube insertion site daily with soap and water during ADL care were also not consistently completed, with several scheduled soap and water cleansings not done.

Medication Administration Records documented that ordered water flushes of the G-tube before, between, and after medications were not completed on at least two documented shifts. Progress notes showed that after the resident’s rectal tube fell out, the medical director’s expectation that the gastrointestinal surgeon be notified was not carried out, and there was no documentation that the rectal tube was replaced or that the surgeon was contacted. Over a period of days, nursing notes documented repeated episodes of vomiting and later diarrhea, as well as G-tube leakage, with orders for CBC, BMP, and KUB imaging; however, no CBC or BMP were drawn or resulted at the facility. When the G-tube leakage worsened, staff documented that the resident’s tube drain and gown were soaked with feed and that the G-tube site was continuously leaking. The resident’s family member reported finding the resident’s abdomen covered with crusted feeding and yellow pus under the gauze at the G-tube site and requested hospital transfer. The resident was admitted to the hospital with fever, abdominal pain, diarrhea, nausea, vomiting, toxic appearance, and a diagnosis of sepsis from multiple suspected sources, including a G-tube site infection with pus-filled drainage, and the G-tube was removed in the hospital due to an abscess and sepsis. An ER physician stated that improper G-tube care, including lack of cleansing and flushes, can lead to infection at the site and that dislodged feeding into the abdominal cavity is also a risk factor.

Removal Plan

• All licensed nurses were educated on the facility's complete Gastrostomy Tube - Feeding and Care policy by the Director of Nursing, MDS coordinator, and Assistant Director of Nursing/Wound Nurse.
• All licensed nurses were educated on the facility's Physician Orders - Entering and Processing policy (including when receiving, entering, and confirming physician/prescriber orders in the EMR) by the Director of Nursing and Assistant Director of Nursing/Wound Nurse.
• All licensed nurses were educated on the facility's Documentation - Electronic Health Record policy (timely, accurate, relevant, complete entries) by the Director of Nursing/designee or Administrator.
• All licensed nurses were educated on the facility's Skin Condition Assessment & Monitoring - Pressure and Non-Pressure policy by the Director of Nursing/designee or Administrator.
• All licensed and certified nursing assistants were educated on the facility's Physician-Family Notification - Change in Condition policy by the Director of Nursing/designee or Administrator.
• An impromptu QAPI meeting was held with the medical director and IDT team to discuss the deficiency and facility action plan.
• The facility completed a facility-wide audit of all residents with gastrostomy tubes to verify: stoma site treatment orders are in place; tube feeding orders are in the EHR; residual checks are on the MAR prior to flushes/medications/bolus feeding or starting a new bottle through the feeding pump; signs/symptoms of intolerance are documented with physician notification; any stoma site skin abnormalities are characterized, documented, and physician notified; care plans are reviewed/updated and interventions are in place and reflected on the TAR.
• The facility will conduct audits 7 days per week for 6 weeks to ensure for residents with gastrostomy tubes: stoma site treatment orders are in place and TAR is signed off; tube feeding orders are in the EHR; residual checks are on the MAR prior to flushes/medications/bolus feeding or starting a new bottle through the feeding pump; signs/symptoms of intolerance are documented with physician notification; any stoma site skin abnormalities are characterized, documented, and physician notified; and a QA tool is completed daily for 6 weeks by the Director of Nursing or designee to verify compliance.