Lack of DON Oversight and Poor Nursing–Therapy Communication on G-Tube Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure the nursing department was directed by a qualified Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported that the facility had been without a DON for several months and acknowledged communication issues between departments, including the absence of a defined process for communicating therapy recommendations and the lack of nursing staff access to therapy documentation. The Assistant Director of Nursing, an LPN, stated that the former DON had left approximately eight months earlier and that the position had not been replaced, leaving her to manage nursing needs to the best of her ability. For one resident reviewed for G-tube management, speech therapy documentation over a period of time recorded that the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). However, nursing progress notes documented that the resident had pulled out her G-tube, that enteral feeding orders were discontinued by a nurse practitioner, and that G-tube site care was initiated. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube was still in place and had not been informed that the G-tube had been removed and not replaced, demonstrating a breakdown in communication about the resident’s G-tube status and care needs.
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