Failure to Follow G-Tube Orders, Label Feedings, and Maintain Tube Site
Penalty
Summary
The deficiency involves the facility’s failure to follow gastrostomy tube (g-tube) feeding orders, properly label feeding bottles and bags, and maintain the g-tube site for one resident dependent on staff for care. On multiple observations, the resident was receiving g-tube feedings via a pump with hanging feeding bags that were not labeled with the type of formula being infused, and a clear bag was connected to a water bag without labeling. An open bottle of the ordered nutritional product was observed at the bedside. On one occasion, the feeding pump alarm was beeping to indicate inactivity, and the alarm continued for at least 15 minutes without resolution. When an RN assessed the infusion, she stated she was unsure of the type of feeding being administered because the bag was not labeled, and acknowledged that feeding bags should be accurately labeled to ensure the correct formula is infused. The resident’s g-tube site was repeatedly observed with brown, thick, adherent drainage and without a dressing, despite an order to clean the g-tube site with normal saline daily and as needed. The wound nurse stated that nurses should be assessing and cleaning tube sites to prevent complications. The resident’s care plan directed nursing staff to use clinical standards of practice in managing the tube, including infusing feeding as ordered and regularly checking the tube site for drainage. These observations and staff statements show that the facility did not implement the ordered care and care plan interventions for g-tube feeding administration, labeling, and site maintenance for this resident.
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