§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on review of facility policies and clinical records, and staff interview, it was determined the facility failed to provide care in accordance with professional standards for care of a gastrostomy tube (G-tube-a surgically placed rubber tube placed into the stomach to deliver nutrition, water, and medications) for one of six residents reviewed. (Resident R1)
Findings include:
Review of facility policy entitled "Administering medications via enteral feeding tube" dated 1/2023, revealed, a slow gentle push with a piston syringe of water may only be done if medication will not flow in by gravity.
Review of facility policy entitled "Irrigation of feeding tubes" dated 1/2023, revealed feeding tubes will be flushed with adequate amount of water to prevent formula residue from adhering to the tube causing a clogged tube.
Review of Resident R1's clinical record revealed an admission date of 1/22/20, with diagnoses that included dysphagia (a condition that causes a person to not be able to swallow), diabetes (condition of improper blood sugar control), and Gastro Esophageal Reflux (acid reflux or heart burn).
Review of Resident R1's clinical record revealed a nurse's progress note dated 2/20/24, that indicated Resident R1 was sent to the emergency room for evaluation due to a foreign object stuck in his/her G-tube.
Review of a transfer form dated 2/20/24, indicated reason for transfer to emergency room was, "G-tube clogged, and something stuck in it." Resident R1 was transferred to the emergency room on 2/20/24, at 9:00 p.m.
Review of emergency department provider note dated 2/20/24, revealed on Resident R1's arrival to the Emergency Room his/her G-tube was removed and replaced with a new G-tube and a tip of a broken off Q-tip was felt in the G-tube that was removed.
Review of Nurse Practitioner post emergency room documentation dated 2/22/24, indicated that Resident R1 was sent to hospital on 2/20/24, due to a foreign object that was inserted into Resident R1's G-tube which became lodged in the G-tube.
During an interview on 3/05/24, at 2:50 p.m. the Director of Nursing confirmed that a foreign object should never be placed in a G-tube. He/she also confirmed that a foreign object should never be used to unclog a G-tube.
28 Pa. Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 03/31/2024
Plan of Correction:
Preparation and/or evaluation of the following Plan of Correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiency. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
R1 will be monitored for concerns with Feeding Tube Patency. Involved staff member retrained on Tube Feeding Process.
An audit will be conducted by the Director of Nursing or designee to determine all Residents with an Enteral Feeding Tube.
The Director of Nursing or designee will provide education on Facility Policy for Managing a Clogged Feeding Tube will be required for all licensed Nursing Staff.
The Director of Nursing or designee will provide education on Managing Clogged Feeding Tubes will be conducted initially and annually going forward with all licensed Nursing Staff.
All Pleasant Ridge Manor licensed Nursing Staff will be required to complete competency for Managing a Clogged Feeding Tube.
During Quality Assurance process 100% of Residents with an Enteral Tube Feeding will be monitored by the Director of Nursing or designee daily on each shift for one (1) month, then 50% of residents with an Enteral Tube Feeding will be monitored weekly on each shift for one (1) month, and then 50% of Residents with an Enteral Tube Feeding will be monitored quarterly until no further issues are noted.
Completion date: 3/31/24
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