Failure to Stop Tube Feeding Leads to Resident's Hospitalization
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services, leading to severe complications. The resident, who had a history of HIV, gastrostomy malfunction, dysphagia, quadriplegia, and malnutrition, was supposed to have their tube feeding stopped at 7:00 a.m. as per physician orders. However, the feeding continued for an additional 6.5 hours, resulting in an excess volume delivery of 1072 ml. This oversight led to the resident experiencing vomiting, cyanosis, and a dangerously low oxygen saturation level of 52%, necessitating emergency transfer to the hospital where they were diagnosed with aspiration pneumonia and acute respiratory failure. The incident occurred because the nurse responsible for the resident's care, LVN A, forgot to turn off the tube feeding due to being busy with other tasks such as administering insulin and performing blood sugar checks. Despite the facility being adequately staffed, LVN A did not seek assistance from other available nurses. The oversight was discovered when a CNA noticed the resident vomiting and reported it to LVN A, who then realized the tube feeding had not been stopped. The resident's condition deteriorated rapidly, requiring immediate medical intervention. Interviews with staff revealed that the facility had policies in place for managing tube feedings, but these were not followed in this instance. The ADON confirmed that LVN A had prematurely signed off on the task of stopping the tube feeding, which contributed to the oversight. The facility's failure to adhere to physician orders and properly monitor the resident's condition led to a serious health crisis, highlighting the critical importance of following established protocols for enteral feeding management.
Removal Plan
- The Director of Nursing/Designee will validate that physician orders for tube feeding are being followed as written.
- LVN A was suspended pending investigation and terminated post investigation.
- The Director of Nursing/Designee will re-educate Licensed Nurses on following physician orders including start and stop times of tube feedings.
- The Director of Nursing/Designee will reeducate Licensed Nurses on assessing residents for complications related to tube feedings which includes monitoring for nausea, vomiting, diarrhea and constipation, gastric distention and bowel sounds, monitoring for aspiration which may include adventitious breath sounds.
- Licensed Nurses and Certified Nursing Assistants will be reeducated by the Director of Nursing/Designee on tube feeding management and prevention of tube feeding complications which includes: Licensed Nurses may hold/pause feeding while ADL care is performed that requires the head of bed to be lowered, Certified Nursing Assistants will notify the licensed Nurse prior to performing ADL care that requires the head of the bed to be lowered to allow for the Licensed Nurse to pause/hold the feeding and resume the feeding once ADL care completed, Certified Nursing Assistants will not adjust the tube feeding, only licensed nurses.
- Nursing Staff not receiving this education will receive prior to their next scheduled shift.
- The Director of Nursing/Designee will randomly interview a minimum of 3 nursing staff members to validate understanding and compliance with tube feeding management and prevention of tube feeding complications.
- Medical Director was notified of the incident and plan for improvement.
- An Ad Hoc QAPI will be held to discuss the contents of this plan.
- The daily monitoring tool for physician orders adherence as written for peg tubes will be utilized. The DON will validate that physician orders for tube feeding are being followed as written.
- The DON will randomly interview nurses and aides to ensure understanding and compliance with tube feeding management and potential complications of tube feeding.
- No staff will be allowed to work until they have received all in-services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incorrect G-tube Flush Volume During Enteral Feeding: A resident with severe cognitive impairment, aphasia, stroke, hemiplegia, and a feeding tube was observed receiving enteral feeding when an RN flushed the G-tube with 30 ml of water before and after the feeding instead of the ordered 60 ml. The RN stated he read the order wrong, and the DON and ADON confirmed the correct flush amount should have been followed.
A resident with moderate cognitive impairment, multiple comorbidities, and NPO status received nutrition and hydration via a gastrojejunal tube with orders for continuous tube feeding, 30 mL water flushes before and after medications via the gastric port, 120 mL free water flushes six times daily, and 30 mL jejunal port flushes every four hours. During observed care, an LPN administered medications and 30 mL water flushes through the gastric port but did not provide the ordered 120 mL free water flush or the 30 mL jejunal port flush, and no additional flushes were given over several hours. Later, another LPN initially attempted to give medications through the jejunal port before being redirected, and documentation on the MAR/TAR showed inconsistent flush volumes of 30–60 mL instead of the ordered 120 mL free water flushes, reflecting failure to consistently implement the prescribed hydration and port-specific flushing regimen.
A resident receiving enteral tube feeding was observed lying with the HOB elevated only 15 degrees while Glucerna was infusing at 60 ml/hr. An LVN started the feeding and was unsure of the correct HOB position, and an RN stated the HOB was not elevated properly to prevent aspiration. Records showed an order to keep the HOB elevated 30-45 degrees or as tolerated and a care plan noting tube feeding related to dysphagia.
GT site care and feeding precautions were not followed for two residents with GTs. One resident with dementia and severe cognitive impairment had a GT dressing left unchanged despite orders for daily cleansing and dressing changes, and drainage was observed at the site. Another resident was observed lying flat in a supine position while receiving continuous GT feeding, even though the CP and OSR required HOB elevation during tube feeding; RN and DON confirmed the ordered positioning was not being followed.
Expired Tube Feeding Formula Left Connected to a Resident: A resident with anoxic brain damage, dysphagia, and a gastrostomy tube was observed with an enteral feeding pump off but still connected and a tube feeding bag that staff said had exceeded the 24-hour limit after opening. Staff confirmed the formula was no longer safe after 24 hours, and the facility policy required accurate labeling and dating of each feeding bag or formula container.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Incorrect G-tube Flush Volume During Enteral Feeding
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident who was fed by enteral means. Resident #11, a [AGE]-year-old female with diagnoses including aphasia, stroke, hemiplegia, and cerebral infarction, had a BIMS score of 0 and was on a feeding tube due to impaired swallowing. Her care plan directed staff to follow the current feeding orders, and the order summary included instructions to flush the enteral tube with 60 ml of water before and after feedings, along with separate flush instructions for medication administration. During observation of a feeding, RN D checked g-tube placement, poured 30 ml of water into the syringe and let it flow by gravity, then poured formula into the syringe and flushed with 30 ml of water after the feeding. During interview, RN D stated he had read the flush order wrong and said the order was 60 ml. The DON stated that if the order was 60 ml, it should have been followed, and ADON J stated the correct flush before and after feedings should be 60 ml. The facility policy stated that enteral formulas and medications are to be administered safely and effectively based on nursing assessment and physician consultation.
Failure to Provide Ordered Hydration and Correct Tube Flushes for Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered hydration interventions and tube flushes for a resident receiving enteral nutrition via a gastrojejunal tube. The resident had moderate cognitive impairment and multiple diagnoses including stroke with hemiplegia, heart failure, kidney disease, diabetes, aphasia, malnutrition, and respiratory failure, and was NPO with tube feeding providing more than half of total caloric intake and at least 501 cc/day of fluid. The care plan and physician orders specified continuous Isosource 1.5 at 55 mL/hr, 30 mL water flushes before and after medications via the gastric port, additional free water flushes of 120 mL six times per day to meet hydration needs, and 30 mL water flushes through the jejunal port every four hours to prevent clogging. On one observed morning medication pass, an LPN paused the jejunal tube feeding, checked residual, flushed 30 cc of water into the gastric port, administered crushed medications via the gastric port, and flushed with another 30 cc of water, then restarted the feeding through the jejunal port. During this episode of care, the LPN did not provide the ordered 120 cc free water flush or the ordered 30 cc jejunal port flush, and no additional flushes were administered by any staff from 8:40 a.m. to 11:53 a.m. The medication and treatment administration record showed an order for a 60 cc flush with the day shift medication administration, a 120 cc flush, and a 30 cc jejunal port flush, but the LPN stated she believed the water used before and after medications and mixed with the medications counted toward the 120 cc flush and acknowledged she had not seen the part of the order requiring a 30 cc flush to the jejunal port every four hours. Later that day, another LPN flushed both the jejunal and gastric ports with 30 cc of water, then initially attempted to administer medications into the jejunal port until redirected by another LPN to use the gastric port, after which the gastric port was flushed with 30 cc of water and then 120 cc of water. Staff reviewed the orders and noted that the 120 cc flush six times per day did not specify which port to use, and documentation on the medication and treatment administration record showed variable flush amounts of 30 and 60 cc rather than the ordered 120 cc free water flushes. The registered dietician and nursing staff acknowledged that documentation reflected inconsistent flush volumes and that residents with tube feedings, such as this resident, were at increased risk of dehydration, and the DON stated that free water flushes were expected to be given as separate amounts from medication flushes and that medications and flushes were to be administered through the correct ports.
Improper Head-of-Bed Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure that Resident 6’s head of bed was elevated to prevent aspiration while receiving enteral tube feeding. During an observation, Resident 6 was lying in bed with the head of bed elevated at a 15-degree angle while an LVN connected the resident to the enteral feeding pump and set it to deliver Glucerna at 60 ml per hour. The LVN then left the room after starting the feeding, and during a concurrent interview stated he was not sure how elevated the head of bed was and believed it should have been elevated to 90 degrees during enteral feeding. During a concurrent interview, an RN observed Resident 6 in the same position with the head of bed still at a 15-degree angle and stated it was not elevated properly to prevent aspiration, noting it was below 30 degrees and should have been elevated to 50 degrees during enteral feedings. Record review showed an active physician order to keep the head of bed elevated 30-45 degrees or as tolerated to prevent aspiration, and the care plan identified that the resident required tube feeding related to dysphagia. The facility did not provide the requested policy and procedure for enteral tube feedings.
GT Site Care and Feeding Position Not Provided as Ordered
Penalty
Summary
Resident 3 had diagnoses including encounter for attention to a GT and dementia, with severely impaired cognition and dependence on staff for multiple activities of daily living. The physician’s order and care plan required GT site care with normal saline, pat dry, and a dry dressing every day shift, and the care plan also directed local GT site care as ordered and monitoring for signs and symptoms of infection. During observation, Resident 3 was found with a GT site dressing dated 4/19/2026 and light brown drainage at the site. RN 1 stated the dressing had not been changed the prior day, and the Treatment Nurse stated the dressing was forgotten and needed to be cleaned and changed daily as ordered to prevent infection. The DON stated licensed nurses were responsible for changing the GT site dressing daily as ordered. Resident 6 had diagnoses including encounter for attention to a GT, obstructive and reflux uropathy, and benign prostatic hyperplasia, and the care plan required head of bed elevation of at least 30 to 45 degrees during and after tube feeding. The order summary also directed staff to elevate the head of bed a minimum of 30 degrees at all times during administration of feedings or medications. During observation, Resident 6 was asleep, lying flat in bed in a supine position while connected to ongoing GT feeding at 50 ml/hr. RN 1 stated the resident should have had the head of bed elevated 30 to 45 degrees during feeding to prevent aspiration, and the DON stated the head of bed should have been elevated at least 30 degrees while on GT feeding.
Expired Tube Feeding Formula Left Connected to Resident
Penalty
Summary
The facility failed to provide necessary care and services for one of two sampled residents receiving enteral feeding. Resident 3 had diagnoses including anoxic brain damage, dysphagia, gastrostomy, and cerebral aneurysm, and the admission history and physical indicated the resident did not have the capacity to understand and make decisions. The order summary showed Isosource 1.5 was ordered at 75 ml per hour for 10 hours via gastrostomy tube, with the feeding to start at 8:00 p.m. and stop at 6:00 a.m. During observation, Resident 3 was lying in bed with an enteral feeding pump next to the bed, and the tube feeding bag was labeled and dated at 9:00 p.m. while the pump was off but still connected to the resident. During interview and record review, staff stated the tube feeding formula was only good for 24 hours once the bag was opened and spiked, and that the bag observed was already expired. Staff also stated the bag should have been discarded and that charge nurses each shift should check the tube feeding bag for expiration. The facility policy required staff caring for residents with enteral feedings to ensure accurate labeling and dating of each feeding bag or formula container, with an expiration date/time per manufacturer or facility protocol.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
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