Failure to Revise Care Plan After Repeated G-Tube Dislodgements
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s care plan updated to reflect repeated changes in condition related to G-tube dislodgement. The resident, admitted with metabolic encephalopathy and documented as having severe cognitive impairment (BIMS score of 99), experienced multiple episodes of pulling out her G-tube between October 10, 2025, and November 13, 2025. Each episode required transfer to the emergency room for G-tube replacement. The care plan, dated October 2, 2025, and subsequently referenced on October 10, 2025, October 13, 2025, and November 12, 2025, identified the resident as being at risk for behaviors related to dementia and G-tube dislodgement, with interventions including use of an abdominal binder and monitoring of behaviors. However, the care plan was not revised after the October 21, 2025, episode despite additional G-tube dislodgements, and the interventions initiated on October 13, 2025, were not incorporated into the written care plan until after the October 29, 2025, incident. The care plan initiated on November 12, 2025, did not include any new interventions and did not reflect changes in condition or the effectiveness of interventions for each episode. Interviews with an LVN and a CNA assigned to the resident showed they were not aware of any behaviors related to the resident pulling out her G-tube, while an RN acknowledged repeated G-tube pulling behaviors beginning October 10, 2025, and that a new intervention was not implemented until November 13, 2025. The DON stated that care plans should be revised with each change in condition and that the IDT should evaluate incidents and revise care plans accordingly, but confirmed there were only two IDT reviews despite six G-tube dislodgement incidents, contrary to the facility’s care plan policy requiring ongoing assessment and revision when the resident’s condition changes or desired outcomes are not met.
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