Failure to Monitor and Manage Tube Feeding Leading to Repeated Aspiration and Harm
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and manage tube feeding and fluid needs for a resident with a gastrostomy tube, and to intervene appropriately when repeated aspiration events occurred. The resident was admitted with a diagnosis of feeding tube (gastrostomy status) and had a care plan directing staff to administer tube feeding and hydration as ordered, maintain the head of bed elevation during and after feeding, and flush the tube with specified amounts of water before and after medications and feedings. Dietary progress notes documented that the resident’s weight was stable and overweight by standard, with tube feeding ordered as Nutren 1.5 at 70 mL/hr for 18 hours and free water flushes (FWF) of 65 mL/hr for 18 hours, providing 1890 calories and 1170 mL of water per day. However, review of the Medication Administration Record (MAR) showed that staff documented providing tube feeding and FWF volumes far in excess of the ordered daily amounts on multiple days, with recorded totals of tube feeding and water flushes that greatly exceeded the prescribed 1260 mL of tube feeding and 1170 mL of FWF in 24 hours. The resident experienced multiple episodes of tube feeding formula oozing from the mouth and nares, along with respiratory compromise, that were documented in progress notes but were not followed by documented reassessment or adjustment of tube feeding orders by the dietitian or medical providers. On one occasion, the resident was found unresponsive with low oxygen saturation and tube feeding seen oozing from the mouth; CPR was initiated, suctioning was performed, and the resident was sent to the hospital. The resident was later readmitted with the same tube feeding and water flush rates, and a subsequent note indicated treatment for aspiration pneumonia. Later MAR entries again showed staff-documented tube feeding and FWF volumes that exceeded the ordered amounts. Another nursing note described the resident with labored breathing, crackles in both lungs, and milky secretions pooling from both nares and mouth, with suctioning performed and an order obtained to send the resident to the hospital via 911. A hospital history note documented concern for overfeeding and aspiration, with admission for septic shock, pneumonia, and urinary tract infection. Despite these events, dietary notes continued to state that the resident’s weights were stable or that weight gain was being evaluated for accuracy, and that no nutritional interventions were needed at that time, even when a dietary note recorded a net weight gain of 22.6% over seven months. A later dietary progress note indicated that the resident remained NPO and continued on the prescribed tube feeding regimen, with concurrent water flushes providing a total of 2132 mL of fluid per day. Nursing progress notes in a subsequent month documented repeated observations of Nutren feed coming out of the resident’s mouth, coarse crackles bilaterally, dyspnea, and the need for frequent suctioning, with the NP initially instructing staff to monitor the resident. Another note described fluid from the mouth, crackles, and continued monitoring, followed by a note that the resident was aspirating from the mouth with shortness of breath and lung crackles, leading to a recommendation from the NP to send the resident to the hospital. Interviews with the NP and dietitians revealed that the NP documented the resident as tolerating tube feeding after aspiration incidents, that the dietitian was not notified of earlier aspiration events or the hospital note about overfeeding, and that the dietitian acknowledged an assessment of tube feeding and water flush rates should be conducted after aspiration incidents. The facility’s own enteral nutrition policy required the RDN to assess energy, protein, and fluid requirements, compare them to ordered formula and flushes, and monitor weight, labs, and physical symptoms, and required nursing to communicate changes such as vomiting and high residuals, but the documented care and communication did not reflect consistent adherence to these requirements for this resident. The facility’s leadership, including the DON, Medical Director, NP, Regional Registered Dietitian, and facility dietitian, acknowledged in interview that the resident had chronic encephalopathy and aspirated off and on, and that dietary staff usually changed orders and tracked tube feeding, aspiration, and labs. However, the Medical Director responded to a question about tube feeding coming out of the resident’s nose by stating that people vomit when they are sick, and there was no documentation that the tube feeding regimen was reassessed or modified in response to the repeated documented episodes of tube feeding formula oozing from the resident’s mouth and nares, the excessive volumes recorded on the MAR, or the significant weight gain. The survey findings concluded that the facility failed to ensure that the resident was assessed and monitored for nutritional and fluid needs and failed to implement interventions when the resident aspirated tube feeding multiple times and gained a significant amount of weight, resulting in harm including cardiac arrest during an aspiration event and multiple hospitalizations after aspiration of tube feeding.
Removal Plan
- Transferred the affected resident to the hospital
- Assessed all tube-fed residents for tolerance, weights, and aspiration signs
- Registered Dietitian and clinical leadership reviewed tube-fed residents’ status
- Convened a QAPI meeting
- Provided education to the dietitian and nursing staff on the enteral feeding policy with completion
- Implemented a structured audit and monitoring process of MARs and progress notes to ensure ongoing compliance and early identification of tube feeding intolerance
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.
GT Not Flushed Before Med Pass: An LPN was observed preparing to give crushed meds through a resident’s GT without first flushing the tube with water. The surveyor stopped the med pass before any meds were given, and both the LPN and DON confirmed the GT had not been flushed as required by the resident’s order and facility policy.
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.
GT Not Flushed Before Medication Administration
Penalty
Summary
The facility failed to flush a gastrostomy tube with water before administering crushed medications to one resident, Resident 87, during an observed medication pass. During the observation on 4/21/2026 at 9:45 a.m., LVN 4 was seen preparing to give crushed medication through the resident’s GT without first flushing the tube with water. The surveyor stopped the LVN before any medication was administered and asked to discuss the GT technique. In the concurrent interview, LVN 4 stated that the GT had not been flushed before medication administration. During a later interview on 4/21/2026 at 3:48 p.m., the DON confirmed that LVN 4 failed to flush Resident 87’s GT with water before medication administration. The DON stated that this technique was important to ensure the GT was not clogged and that the resident did not aspirate or need GT replacement. Resident 87’s record showed an admission date of 1/22/2018 and a re-admission on [DATE], with a diagnosis including encounter for attention to gastrostomy. The order summary indicated 30 cc of fluids may be given via GT before and after medication administration, and the facility policy stated the enteral feeding tube should be flushed with at least 30 cc of water before and after medications are administered.
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