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Based on record review and interview with facility staff and complainant, the facility failed to follow and/or update the nursing plan of care for one patient (patient #1) with a physician's order for a nasogastric (NG) tube, failed to implement the physician's order for placement of the NG tube, failed to note the physician's order for the NG tube in a timely manner, and failed to educate the patient and/or family member on the reasons for the use of and the consequences of not using the NG tube for patient #1 who had an admitting diagnosis of bowel obstruction.

The failed practice had the potential to affect all patients (unknown number) on the unit with an NG tube.

Findings included:

1. Record review on 07/18/12 of patient #1's History and Physical, dictated by physician #1 on 10/05/11 at 0925, revealed that "patient was an 88 year old man who comes in for just less than a day with history of abdominal pain. It was sharp and excruciating and occurred yesterday after eating. He has not had a bowel movement since Sunday and only had a small one at noon. He tried to give himself an enema, but that did not work. He has had some nausea and vomiting. He has NG tube in place. He had a CT scan of his abdomen showed patient with a nonspecific dilatation of the stomach and small intestine and small right inguinal hernia. Note, he does have a large amount of stool in the colon. Case of patient having constipation and probably obstipation with small bowel distention and dilation as well. Patient has a history of Meckel diverticulum with intra-abdominal hernia status post repair in 2010. Patient also with Parkinson and history of chronic constipation. Patient also with chronic kidney disease. Plan is for a soapsuds enema. We will start him on bowel regimen. We will have GI (gastrointerologist) see him. Continue supportive care. Continue prophylaxis. I will discuss this with the daughter."

2. Record review on 07/18/12 of patient #1's emergency room physician's telephone orders, dated 10/05/12 at 0350, included but was not limited to the following: "admit to med/surg, Dx (diagnosis) bowel obstruction, Diet: NPO (nothing by mouth), and NGT (nasogastric tube to intermittent with wall suction."

3. Record review on 07/18/12 to 07/19/12 of patient #1's clinical documentation record, dated 10/05/11 to 10/07/11, revealed the NG tube was identified as a problem/intervention on the nursing plan of care. Under goals, the plan of care documented the following: "1. The patient will receive care which reflects an ongoing process of interdisciplinary care based on their specific care needs. Coping responses to hospitalization will be assessed and addressed. 2. The patient and/or significant others can expect to be involved in the plan of care with attention to cultural and religious beliefs, privacy, and confidentiality. 3. The patient and/or other significant others will participate in the process of coordination of resources in preparation for discharge. 4. The patient and/or significant others will receive teaching about the nature of their health conditions, procedures, treatments, self-care and post discharge care. Verbalization of questions concerns will be encouraged. Patient education, which is an interactive, interdisciplinary teaching process is prioritized based on the ongoing assessment of individual learning needs. 5. The patient and/ or significant others will have their environment and care managed to minimize risk to themselves and others. "

4. Record review on 07/18/12 of patient #1's clinical documentation record, dated 10/05/11 at 1105 AM and created by Registered Nurse (RN) #1 on 10/05/11 at 1831 PM revealed the following statement: " Per PCA (Patient Care Assistant) report, patient up to bedside commode and pulled out NG tube. Notified Dr. ______, (Physician # 1) per physician ' s order, hold re-placing NG tube."

5. Record review on 07/19/12 of gastroenterologist ' s (physician #2) order for patient #1, dated 10/05/11 at 1210 PM, included the following: Replace NG tube. The order was documented as entered into order system by clerical staff at 1250 PM. The order was documented as noted by RN # 1 at 1800 PM. In addition, beside the order for the placement of the NG tube was a small square. The other orders on the page were checked off. Review of physician #2's progress notes for patient #1, dated 10/05/11 at 1270 PM included the following notation under plan " NGT LIWS (NG tube low intermittent wall suction). "

6. Record review of clinical documentation record from 10/05/11at 1105 AM until 10/06/11 at 0053 AM revealed no further documentation by nursing staff regarding the NG tube. There was no documentation discussing why the order to replace the NG tube was not carried out. There was no documentation that a physician was notified regarding the order to replace the NG tube not being carried out. On 10/06/11 at 0053 and created in the clinical record on 10/06/11 at 0101 AM by RN #2 revealed the following: " Sleeping from 199 (corrected to 1900) until 2200, refused golightly and NG tube, daughter at bedside agreed with patient. Unable to swallow liquids without coughing. PO (by mouth) medications on hold. Dr. _____ (physician #3) on call for Dr. ____ (physician #2), notified, new orders received. Medicated with Zofran for abdominal discomfort, and with morphine for complaints of severe pain. Resting comfortable at this time, daughter at bedside. "There was no documentation in the clinical record of a discussion between patient #1and/or patient #1's daughter regarding why the NG tube was ordered and the possible consequences of not re-placing the NG tube. In addition, during the six hours between the written order by the gastroenterologist (physician #2) to replace the NG tube and the notation of the order by RN #2, there was no documentation by nursing staff that patient #1 and/or the patient #1's daughter was in agreement with not replacing the NG tube nor was there documentation that the gastroenterologist (physician #2) was aware the patient and/or the patient ' s daughter did not want the NG tube replaced.

Continued review of patient #1's clinical documentation record revealed that on 10/06/11 at 0930AM and documented by RN #3 on 10/06/11 at 1357 PM revealed the following: " Dr. _____ (Physician #2) called by nurse and reported to the doctor that the NG tube remains out. Received order to keep patient NPO (nothing by mouth),and to hold PO (by mouth) medications. Received order to first give fleets enema, then changed to suppositories. Informed doctor of patient ' s family ' s concerns. Notified family of call to doctor. "

At 10/06/11 at 1030 AM and documented on 10/06/11 at 1400 by RN #3, " patient ' s family assisted patient to side of bed, patient vomiting. Cleaned patient ' s face with wash cloth. Family stated patient vomited a lot.: At 1100 AM, Dr. _______ (Physician #2) on the floor to see patient. Patient vomiting. Dr. ______ (Physician #2) asked for an NG tube and lubrication. Pulse ox placed on patient prior to placement of the NG tube."

At 1115 AM, "Dr. ______ (Physician #2) with patient when code called, Dr. Reported that patient stopped breathing. At 1145 AM, patient was transferred to ICU."

7. Record review on 07/18/12 of patient #1 ' s Death Summary, dated 10/11/11 at 1215 PM revealed the following statements by Physician #3: " He had an NG tube in place and patient removed it a couple of times while in the hospital. On the morning of October 6th (2011), the patient started vomiting, aspirated, and went into respiratory arrest. Required an emergent intubation and emergency service. Patient became hypotensive requiring vasopressors with Levophed. Patient was intubated, receiving total ventilatory respiratory support, on Levophed , was diagnosed with a status post pulseless electrical activity arrest, acute ST elevated MI, acute renal failure with profound metabolic lactic acidosis, aspiration pneumonia, and septic shock secondary to intra-abdominal catastrophe. On the early hours of October 7th, patient ' s family requested do not ressussicate/do not intubate (DNR/DNI), and around 7:00 AM, patient was declared dead. "

8. Interview on 07/18/12 at 11:00 AM with the Director of Risk Management revealed that she was familiar with the complaint regarding patient #1. She stated she has referred this case to Medical Peer Review. She further explained that whenever there was a complaint, part of the process was to refer to Medical Peer Review. She stated the next meeting for Medical Peer Review would be in August 2012. She stated she had acknowledged the complaint by sending a letter to the complainant.

9. Interview on 07/18/12 at 12:55 with RN #1 who worked the 7:00 AM to 7:00 PM shift revealed the following: She did not remember patient #1. She confirmed that when a square is beside a physician ' s order that means she has not completed the order. She stated she would have gone over the physician ' s orders that had not been completed with the next shift. She was unable to explain why there was a six hour difference between when the physician ordered the NG tube replaced and when she noted the order for the replacement.

10. Interview on 07/19/12 at 4:00 PM with the complainant revealed the following. She indicated she was the daughter of patient #1 and had stayed with patient #1 during a large part of his hospital stay. She stated that she had been with her father since late evening of 10/05/11 when she took him to the facility emergency room until the morning of 10/06/11 prior to the time he coded. She stated that on the morning of 10/05/11, she had initially agreed with patient #1 ' s wish to not have the NG tube in because he was uncomfortable when the NG tube was in place. She stated that later in the day sometime after 5:30 PM and into the night, she voiced concerns to the nursing staff regarding the amount of fluid coming from his mouth. She described it as " brown and stringy " . She stated she knew the NG tube needed to go back in. She stated she was told by RN #2 that she needed an order to replace the NG tube and she would have to get in touch with a physician to get an order to replace the NG tube. The complainant recalled that she continuously asked RN#2 if she had heard from the physician regarding replacing the NG tube and was told she had not heard from the physician.

12. Interview on 07/18/12 at 7:00 PM with RN #2 who worked the 7:00 PM to 7:00 AM shift revealed that she recalled patient #1 and his daughter. She described his daughter as " demanding " . She stated that patient #1 and his daughter did not want the NG tube in place. She recalled that she documented they did not want the NG tube in place because she had spoken with the physician on call (physician #3) and he had instructed her to document their refusal of the NG tube. She indicated that if she had placed an NG tube in the patient, she would have had to " hold him down " . She stated that she did not remember patient #1's daughter asking her to contact a physician because she wanted the NG tube replaced. She confirmed that she contacted the physician on call after attempting to contact other physicians. She did not remember if she attempted to contact physician #2. She stated that she thought she had documented her unsuccessful attempts to contact a physician during the night. She was unable to recall a specific reason why she was attempting to contact a physician regarding patient #1.