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Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to provide care in a safe setting for 1 patient (#1) of 4 patients reviewed for tube feedings.

The findings included:

During the survey it was found one patient (#1) was admitted to Hospital B on 6/28/16 for a left hip Arthroplasty (hip replacement) and then discharged on 6/30/16. The patient was readmitted to the facility on 7/1/16 with a diagnosis of a perforated viscus (leakage of air or bacterial products into the peritoneum). The patient was admitted to ICU (Intensive Care Unit) where he remained until his transfer to another acute care hospital on 7/9/16. On 7/8/16 a Dobhoff feeding tube was inserted at Hospital B. On 7/9/16, at Hospital B, tube feedings were started prior to confirmation of the feeding tube placement and the patient became tachycardic (increased heart rate), tachypnic (increased respirations), and his oxygen saturations dropped. On 7/9/16, x-ray confimation revealed the Dobhoff feeding tube was inserted into the trachea and down the right bronchus through the lung and into the pleural cavity. In addition, a pneumothorax (build up of air in the pleural space) was found, requiring a chest tube to be inserted.

During a conference on 9/8/16 at 3:25 PM, in the Administration conference room, with the Administrator, the Director of Quality Management, and the Metro Chief Quality Officer, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment or death) at 42 CFR PART 482.13 Condition of Participation, Patient Rights.

Review of an Immediate Action Plan, which removed the Immediate Jeopardy on 9/8/16, revealed the following actions were implemented:
(1) Dobhoff Tubes (DHT):
(a) Only Nasogastric Tubes will be inserted by the Intensive Care Unit (ICU) Registered Nurses (RN). All DHT tube insertions will be done in radiology under fluoroscopy. All ICU RNs were notified by an email sent from the Nurse Manager on 8/24/16 and during an ICU staff meeting on 8/29/16.
(b) A DHT competency will be documented and kept in each ICU RN's folder.
(c) A sign was posted on the facility's locked supply cabinets which stated "...until individual competencies are completed, Dobhoff tubes will only be placed by Radiology...always ensure there is an order to place the Dobhoff Tube...always verify there is an order for an x-ray to confirm placement...never remove guide wire until the correct Dobhoff placement is verified by x-ray (KUB)...never start tube feeding before correct Dobhoff placement is verified by x-ray (KUB)...always document location of the Dobhoff tube (i.e. which nare, centimeter mark)...always verify the tube feeding order for correct formula and rate..." completed 9/8/16.
(d) ICU staff were given additional training begining on 9/8/16-9/12/16 regarding Dobhoff tube management. Those who had not completed the training will not be allowed to begin their shift until the training is complete, implemented 9/8/16.
(e) Dobhoff tubes were removed from any nursing unit supplies; they are only available in materials management; there was notification stating "Insertion must be done in radiology only" and signed by Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Operating Officer (COO), completed 9/8/16.

Refer to A-0144

Based on review of facility policy/protocols, medical record review, review of facility documentation, and interview, the facility failed to provide care in a safe manner for 1 patient (#1) of 4 patients reviewed for tube feedings.

The findings included:

Review of facility policy "Tube Feeding Placement Protocol" with no date, revealed "...Critical Care RN [Registered Nurse] to place feeding tube at bedside...portable KUB [x-ray of kidney, ureter, bladder] for tube placement...if KUB results state feeding tube is in distal stomach or duodenal then may use feeding tube..."

Review of a Mosby Clinical Skills protocol (the protocols used by the facility) dated 2016 revealed "...gastric feeding, the most common type of enteral nutrition, allows tube feeding formulas to enter the stomach and pass gradually though the intestinal tract to ensure absorption...preparation: verify the practitioner's order for the formula, rate, route, and frequency...verify tube placement...obtain radiographic or other approved confirmation of correct placement before the first use for feeding or when assessment findings...or patient complaints suggest tube displacement..."

Review of facility policy Hand-Off Communication, last revised on 2/23/16, revealed "...hand off communication refers to the process of providing patient specific information from one caregiver to another to ensure continuity and safe patient care. Hand off communications shall be performed in such a manner to prevent errors and improve safety of care delivered across the continuum of health care services...this will include the accurate information about the patient's care, treatment and services, current condition, and any recent or anticipated changes...the method of communication includes either verbal or written/electronic documentation of the following elements when appropriate and pertinent...current condition...any other pertinent information such as ongoing treatment, changes in condition, recent laboratory and radiological tests..."

Medical record review revealed Patient #1 was admitted to Hospital B on 7/1/16 with diagnoses including Sepsis Secondary to Peritonitis secondary to Perforated Viscus and three day status post Left Hip Arthroplasty (hip replacement). Further review revealed the patient was transferred to another hospital on 7/9/16.

Medical record review of an admission History and Physical dated 7/1/16 at 2:46 PM, revealed the patient was discharged from the facility on 6/30/16 after a Left Hip Arthroplasty. The patient was readmitted to Hospital B on 7/1/16, diagnosed with a Perforated Viscus and Peritonitis, was taken to surgery on 7/1/16 for an exploratory laparotomy, and then admitted to the Intensive Care Unit (ICU).

Medical record review of an electronic Physicians order dated 7/1/16 at 5:50 PM revealed "...nasogastric tube [NGT]...suction, low intermittent..."

Medical record review of an electronic Physicians Order dated 7/3/16 at 7:57 AM revealed "...tomorrow 7/4/16, we will start tube feedings via [by] the NG [nasogastric] tube..." Further review revealed "...Nutrition evaluation and Treat...manage TF [tube feeding]..."

Medical record review of a Surgery Progress Note dated 7/4/16 at 2:18 PM revealed "...plan to start enteral nutrition...has NGT for feedings..."

Medical record review of a Dietary Assessment dated 7/4/16 at 3:55 PM revealed "...tube feedings...vital high protein 70 ml/hr [milliliter per hour]...advance slowly at 20 ml/hr x [times] 12 hours and advance 10 ml/hr every 12 hours as tolerated to a goal of 70 ml/hr...flush with 25 ml of free water every 6 hours..." Further review revealed "...special instructions: initiate TF's when OK with [named physician]..."

Medical record review of a Nurse's Note dated 7/4/16 at 7:30 PM revealed "...NGT patent...TF 20 ml/hr...Vital HP [High Protein] formula..."

Medical record review of a Nurse's Note dated 7/6/16 at 8:00 PM revealed "...TF off until further notice...increased residual..."

Medical record review of an electronic Physicians Order dated 7/8/16 at 7:30 AM revealed "...nasogastric tube...withdraw...suction: clamped..."

Medical record review of a Surgery Progress note dated 7/8/16 at 12:58 PM revealed "...off ventilator...speech therapy to follow for swallowing, may need feeding tube in a few days if unable to swallow..."

Medical record review of a Speech Therapy consult dated 7/8/16 at 6:21 PM revealed "...pt. [patient] is not ready for a modified barium swallow study or for oral feedings...suggest alternative feedings..."

Medical record review of a Nurse's Note dated 7/8/16 at 11:41 PM revealed "...tubes: Dobhoff Feeding Tube (DHT) patent...inserted...position checked..."

Medical record review of the electronic Physicians Orders for 7/8/16 and 7/9/16 revealed no physicians order for a Dobhoff feeding tube.

Medical record review of an Abdominal KUB x-ray completed 7/9/16 at 5:56 AM, and read by the Radiologist at 10:41 AM, revealed "...contrast noted within the colon...the feeding tube is not definitely seen on this exam..."

Medical record review of a Nurse's Note dated 7/9/16 at 9:00 AM revealed "...tube feed route interventions TF: DHT...10 ml/hr..."

Medical record review of a Nurse's Note dated 7/9/16 at 11:30 AM revealed "...TF discontinued...stopped d/t [due to] pt. c/o [complaints of] pain the abdomen..."

Medical record review of a Chest Decubitus x-ray (x-ray projection which is made with the patient lying on their side and the x-ray beam horizontal to the floor) dated 7/9/16 at 2:17 PM revealed "...status post feeding tube insertion which is unable to be followed beyond the cervical [neck] region..." Further review of an Addendum revealed "...the feeding tube extends into the right mainstem bronchus into the right pleural space with the distal tip located in the right costophrenic [rib and diaphragm area] angle..."

Medical record review of a Respiratory Therapy flowsheet dated 7/9/16 at 2:31 PM revealed "...O2 [oxygen] saturations 88% [normal 92-100% (percent)] on 4/lpm [liters per minute]...change O2 to 50% Venti-mask, pt. is mouth breathing...saturations came up to 93%..."

Medical record review of a Hospitalist Progress note dated 7/9/16 at 3:00 PM revealed "...pt. with abrupt changes in status after beginning TF...CXR [chest x-ray] repeated with apparent overload. Clinically he has developed tachycardia [elevated heart rate] of 144 he also complains of a lot of pain after tube feedings started per the DHT...the DHT not clearly seen on KUB but the weight tip is not seen in the chest. Repeat films ordered..."

Medical record review of a Surgery Progress note dated 7/9/16 at 3:50 PM revealed "...spoke with wife and daughters. Spoke with [named hospitalist]. Patient was doing well but has some generalized abdominal pain 4 hours ago...as soon as the tube feedings started pt. had acute onset abdominal pain, tachycardia, and tachypnea...evaluation for gastric ulcer, pneumoperitoneum, pulmonary embolus..."

Medical record review of a CT [computerized tomography] scan of the chest dated 7/9/16 at 4:11 PM revealed "...status post feeding tube insertion which extends into the right mainstem bronchus peripherally into the right pleural space. The distal tip of the feeding tube is adjacent to the mid right lobe of the liver in what appears to be a subdiaphragmatic location...small pneumothorax [air in the lung] in the anterior inferior right hemothorax..."

Medical record review of a Hospitalist Progress note dated 7/9/16 at 5:10 PM revealed "...CT scan shows feeding tube in trach [trachea] and to the pleura area of the right lung. Discussed with the surgeon...will place a chest tube in the right side...pleural effusion present..."

Medical record review of a Procedure Note dated 7/9/16 at 6:18 PM revealed "...36 French Chest Tube...400 cc [cubic centimeters] turbid fluid..."

Medical record review of a Surgery Progress note dated 7/9/16 at 6:27 PM revealed "...CT reviewed...feeding tube went into lung out pt. lung into the pleural space. Most likely the tube did not enter the peritoneal cavity...spoke with [named cardiac thoracic surgeon] who was on-call...he suggested removing the DHT and placing a chest tube...I spoke with the family [wife, daughter] regarding the injury and the potential diagnoses and the need for a chest tube now...they want to transfer the pt. to [another hospital], I am agreeable but feel chest tube needs to be placed emergently so he does not develop a tension pneumothorax [progressive buildup of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space] during transfer..." Further review revealed "...chest tube placement went well..."

Medical record review of an Admission History and Physical from the receiving hospital on the day of the patient's transfer, 7/9/16, revealed "...was on the ventilator for 7 days...a swallowing study showed a delay in swallowing so a feeding tube was placed that went into his trachea and into the lung and chest cavity so a CT [chest tube] was placed at an outside hospital [Hospital B]..."

Medical record review of an Attending Physician note at the receiving hospital dated 7/11/16 at 10:48 AM [noted as late entry] revealed "...currently with pneumonitis secondary to transbronchial tube feed placement and insufflation of the tube feeds in the pleural cavity...he has a high risk for developing empyema [buildup of pus in the lungs] we will continue to maintain the chest tube...will assess his oropharyngeal dysphagia with a swallow evaluation and start oral nutrition or place tube feed or other access for enteral nutrition..."

Review of facility documentation dated 7/8/16 revealed "...admitted with abdominal pain, distention and perforated viscus. On 7/8/16 at 11:49 PM a DHT was inserted into the patient's lung (instead of stomach)...KUB was ordered 5+ [plus] hours after placement. Tube feedings was started by oncoming day shift nurse. 2 hours into feeding, patient began to develop pain. It was determined at that time the DHT was not in the stomach and was actually in the lung. It was determined that the patient had a pneumothorax which required a chest tube. The patient was later transferred to another facility..."

Review of a letter written by the Radiologist, dated 8/18/16 with no time, revealed "...a KUB was done the morning of 7/9/16 at 5:56 AM. I read and signed off on the KUB at 10:41 AM. Then the patient came down for a chest x-ray on the same day, 7/9/16 at 2:17 PM. I read and signed off on the chest x-ray at 4:13 PM. At this time I was unable to visualize the feed tube beyond the cervical region. Shortly thereafter, I spoke with [named surgeon] and said a CT scan would be more definitive. A CT scan was done at 4:11 PM and the film was read at 4:32 PM..."

Review of facility documentation with no date revealed an alert was sent to all facility campuses regarding the insertion of feeding tubes. Further review revealed "...patient had tube feeding started after DHT was placed without verification of placement. Upon insertion, the guidewire was removed before the DHT was completely advanced...nurse 1 placed DHT and there was a delay in placing order for KUB. Nurse 1 sat tube feedings up in patient's room. During hand-off, nurse 1 told nurse 2 that tube feeding was 'good to go'. Nurse 2 started tube feeding without reviewing x-ray results..."

Telephone interview with the patient's family member on 8/29/16 at 9:45 AM, revealed "...the nurses had tried to place a feeding tube but were unsuccessful...the night shift nurse told us...could pass a feeding tube in less than 30 seconds...he told us he had passed the tube the first attempt...there was an x-ray machine right outside the door but they did not do the x-ray until 5:00 AM or 5:30 AM the next morning...they started the tube feedings around 8:30 or so...when Physical Therapy came in to get him out of bed later, his blood pressure dropped, he became extremely short of breath and his oxygen saturations dropped...the doctor told me that the feeding tube was placed into his lung and that this lung was punctured...they put a chest tube in..." Further interview revealed "...we requested the transfer to [another hospital] because he was just not getting any better..."

Interview with RN #1 on 8/30/16 at 1:10 PM, in the conference room, revealed the nurse provided care for the patient on 7/9/16 during the dayshift. Further interview revealed "...the tube feedings were hanging in the patient's room but they were not infusing...his wife said they had changed the patient's formula...the feeding tube was present when I went into the room...normally after a DHT placement we get a KUB to confirm placement...I was told the KUB had been done by the night shift nurse so I started the tube feedings around 9:00 AM...he did not complain of any pain at that time...about 2 hours after the feedings were infusing he complained of abdominal pain...there was some abdominal distention...later he started complaining of shortness of breath, his oxygen saturations dropped...I stopped the tube feedings and then called [named surgeon] and [named hospitalist]...a chest x-ray was ordered...the radiologist said they did not see the tip of the tube so they ordered a PA [posterior to anterior] chest x-ray to see if they could see it from the side view but they could not see it there...the patient continued to deteriorate so they ordered a CT scan of the abdomen and the patient went down for the scan..." Continued interview revealed "...I was told by the hospitalist to pull the DHT out but then the surgeon said I might should have left it in place but I had already pulled the tube out..." Further interview revealed "...the patient had developed a pneumothorax and required a chest tube prior to transfer to [another hospital]...the patient's family requested the patient be transferred..."

Interview with the ICU Nurse Manager on 8/30/16 at 1:45 PM, in the conference room, revealed "...I found out about the feeding tube and the pneumothorax after the patient had left our facility...the ICU nurses were the only nurses in the facility who inserted the DHT at that time...the nurse who inserts the feeding tube is the one who should order the KUB...if the results are not back at the end of their shift, they should make that very clear to the oncoming nurse and the oncoming nurse should check that before starting the tube feedings...the night shift nurse set the tube feedings up in the room to have them ready to be started but the day shift nurse was the one who started it...she said that the night shift nurse had told her in report that everything was 'ready to go' so she thought that meant the KUB was confirmed...she started the tube feedings at 10 ml/hr..."

Interview with RN #2 on 8/30/16 at 2:50 PM, in the conference room, revealed the nurse worked the 7 PM-7 AM shift on 7/8/16. Further interview revealed "...the first time I tried the DHT it was unsuccessful because the patient kept coughing and did not tolerate it very well...I waited a few minutes then inserted the feeding tube...it only took about 45 seconds to do it...it was textbook easy...the KUB was not done until 5:00 AM...I did not start the tube feedings due to the KUB not being read on my shift...I told the day shift nurse the KUB had been completed and everything was ready to go...I had laid the tube feedings out...I had not received the radiology results before I left that morning..."

Interview with the Director of Quality Management on 8/30/16 at 3:05 PM, in the conference room, revealed "...we found out the tube was in the patient's lung on 7/9/16 once the x-ray was confirmed...I think the nurse manager was contacted by the ICU nurses related to the family wanting the patient transferred...the patient started having abdominal pain and coughing after the tube feedings were started...a chest x-ray was done and the patient had a CT scan which confirmed the feeding tube was in the patient's lung..."

Interview with the surgeon on 8/30/16 at 4:05 PM, in the conference room, revealed "...I was called on 7/9/16 and told the patient was having increased abdominal pain...the patient suddenly developed tachycardia, tachypnea, and his oxygen saturations had dropped after the tube feedings had been initiated by the DHT...a CT scan on 7/9/16 revealed the feeding tube was located in the right main stem and the right pleural space...there was also indication of a pneumothorax...we pulled the feeding tube out and inserted a large chest tube...the patient's family requested the patient be transferred...his KUB and chest x-ray did not show the tube initially but further radiological studies revealed the weighted tip was observed around the cervical area..."

Interview with the radiologist on 9/7/16 at 1:13 PM, in the conference room, revealed "...I am not the radiologist who reviewed the x-rays [on 7/9/16] but I have reviewed them since then...a KUB x-ray is normally done following placement of a DHT and prior to starting tube feedings...sometimes the order is for a routine KUB and sometimes they order it STAT [immediately]...for this patient a film was requested to confirm placement of a DHT...I am not sure when the feeding tube was placed but the order was received and the film was done around 5:30 AM on 7/9/16...when the radiologist read the x-ray the results showed there was no confirmation the feeding tube was there...we didn't know where the tube was...the chest decubitus x-ray which was done after this showed the distal tip of the feeding tube was not seen beyond the cervical region and then an addendum was noted which revealed the feeding tube extended into the right mainstem bronchus into the pleural space...the distal tip was located in the right costophrenic angle [cervical area]...a CT scan was done which showed the placement of the DHT in the right mainstem and a small pneumothorax on the right side..."

Interview with the Director of Quality Management on 9/7/16 at 1:42 PM, in the conference room, revealed "...this happened on Saturday and the nurse came to me on Monday during our skills day and told me he had placed a feeding tube into a patient's lung and the tube feedings were started..." Further interview confirmed the feeding tube was inserted into the patient's right mainstem and pleural cavity and the tube feedings were initiated prior to confirmation of the feeding tube placement, which resulted in the patient's deterioration. Further interview confirmed the staff failed to ensure clear communication during the shift to shift handoff. Further interview confirmed the staff failed to follow the facility's policy/protocol.

Interview with the Chief Nursing Officer (CNO) on 9/8/16 at 4:55 PM, in the conference room, confirmed the feeding tube was inserted into the patient's lung and a pneumothorax was diagnosed. Further interview confirmed there was a delay in obtaining the confirmation x-ray for the tube and the tube feedings were started prior to x-ray confirmation, which resulted in the patient's deterioration. Further interview confirmed the staff failed to follow the facility's policy.

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to provide nursing services to prevent injury for 1 patient (#1) of 4 patients reviewed for tube feedings.

The findings included:

During the survey it was found one patient (#1) was admitted to the facility on 6/28/16 for a left hip Arthroplasty (hip replacement) and then discharged on 6/30/16. The patient was readmitted to Hospital B on 7/1/16 with a diagnosis of a perforated viscus (leakage of air or bacterial products into the peritoneum). The patient was admitted to ICU (Intensive Care Unit) where he remained until his transfer to another acute care hospital on 7/9/16. On 7/8/16 a Dobhoff feeding tube was inserted at Hospital B. On 7/9/16, at Hospital B, tube feedings were started prior to the confirmation of the feeding tube placement and the patient became tachycardic (increased heart rate), tachypnic (increased respiratory rate), and his oxygen saturations dropped. On 7/9/16, x-ray confimation revealed the feeding tube was inserted into the trachea and down the right bronchus through the lung and into the pleural cavity. In addition, a pneumothorax (build up of air in the pleural space) was found, requiring a chest tube to be inserted.

During a conference on 9/8/16 at 3:25 PM, in the conference room, with the Administrator, the Director of Quality Management, and the Metro Chief Quality Officer, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment or death) at 42 CFR PART 482.23 Conditions of Participation, Nursing Services.

Review of an Immediate Action Plan which removed the Immediate Jeopardy on 9/8/16 revealed the following actions were implemented:
(1) Dobbhoff Tubes:
(a) Only Nasogastric Tubes will be inserted by the Intensive Care Unit (ICU) Registered Nurses (RN). All Doffhoff tube insertions will be done in radiology under fluoroscopy. All ICU RNs were notified by an email sent from the Nurse Manager on 8/24/16 and during an ICU staff meeting on 8/29/16.
(b) A DHT competency will be documented and kept in the ICU RN's folder.
(c) A sign was posted on the facility's locked supply cabinets which stated "...until individual competencies are completed, Dobhoff tubes will only be placed by Radiology...always ensure there is an order to place the Dobhoff Tube...always verify there is an order for an x-ray to confirm placement...never remove guide wire until the correct Dobhoff placement is verified by x-ray (KUB)...never start tube feeding before correct Dobhoff placement is verified by x-ray (KUB)...always document location of the Dobhoff tube (i.e. which nare, centimeter mark)...always verify the tube feeding order for correct formula and rate..." completed 9/8/16.
(d) ICU staff were given additional training beginning 9/8/16-9/12/16 regarding Dobhoff tube management. Those who had not completed the training will not be allowed to begin their shift until the training is complete, implemented 9/8/16.
(e) Dobhoff tubes were removed from any nursing unit supplies; they are only available in materials management; there was notification stating "Insertion must be done in radiology only" and signed by Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Operating Officer (COO) completed 9/8/16.

Refer to A-0395

Based on review of facility policy, review of facility documentation, medical record review, and interview, the facility failed to provide nursing services to prevent injury for 1 patient (#1) of 4 patients reviewed for feeding tubes.

The findings included:

Review of facility policy "Tube Feeding Placement Protocol" with no date, revealed "...Critical Care RN [Registered Nurse] to place feeding tube at bedside...portable KUB [x-ray of kidney, ureter, bladder] for tube placement...if KUB results state feeding tube is in distal stomach or duodenal then may use feeding tube..."

Review of a Mosby Clinical Skills protocol (protocols used by the facility) dated 2016 revealed "...gastric feeding, the most common type of enteral nutrition, allows tube feeding formulas to enter the stomach and pass gradually though the intestinal tract to ensure absorption...verify the practitioner's order for the formula, rate, route, and frequency...verify tube placement...obtain radiographic or other approved confirmation of correct placement before the first use for feeding or when assessment findings...or patient complaints suggest tube displacement..."

Review of facility policy Hand-Off Communication, last revised on 2/23/16, revealed "...hand off communication refers to the process of providing patient specific information from one caregiver to another to ensure continuity and safe patient care. Hand off communications shall be performed in such a manner to prevent errors and improve safety of care delivered across the continuum of health care services...this will include the accurate information about the patient's care, treatment and services, current condition, and any recent or anticipated changes...the method of communication includes either verbal or written/electronic documentation of the following elements when appropriate and pertinent...current condition...any other pertinent information such as ongoing treatment, changes in condition, recent laboratory and radiological tests..."

Review of a sample Situation, Background, Assessment, Recommendation (SBAR) (form used for shift to shift report) revealed a section for GI (gastrointestinal) which included "tube type".

Medical record review revealed Patient #1 was admitted to Hospital B on 7/1/16 with diagnoses including Sepsis Secondary to Peritonitis secondary to Perforated Viscus and three day status post Left hip Arthroplasty (hip replacement). Further review revealed the patient was transferred to another hospital on 7/9/16.

Medical record review of an admission History and Physical dated 7/1/16 at 2:46 PM, revealed the patient was discharged from the facility on 6/30/16 after a Left Hip Arthroplasty. The patient was readmitted to Hospital B on 7/1/16, diagnosed with a Perforated Viscus and Peritonitis, taken to surgery on 7/1/16 for an exploratory laparotomy, and then admitted to the Intensive Care Unit (ICU).

Medical record review of an electronic Physicians order dated 7/1/16 at 5:50 PM revealed "...nasogastric tube [NGT]...suction, low intermittent..."

Medical record review of an electronic Physicians Order dated 7/3/16 at 7:57 AM revealed "...tomorrow 7/4/16, we will start tube feedings via [by] the NG [nasogastric] tube..." Further review revealed "...Nutrition evaluation and Treat...manage TF [tube feeding]..."

Medical record review of a Surgery Progress Note dated 7/4/16 at 2:18 PM revealed "...plan to start enteral nutrition...has nasogastric tube for feedings..."

Medical record review of a Dietary Assessment dated 7/4/16 at 3:55 PM revealed "...tube feedings...vital high protein 70 ml/hr [milliliter per hour]...advance slowly at 20 ml/hr x [times] 12 hours and advance 10 ml/hr every 12 hours as tolerated to a goal of 70 ml/hr...flush with 25 ml of free water every 6 hours..." Further review revealed "...special instructions: initiate TF's when OK with [named physician]..."

Medical record review of a Nurse's Note dated 7/4/16 at 7:30 PM revealed "...NGT patent...TF 20 ml/hr...Vital HP [High Protein] formula..."

Medical record review of a Nurse's Note dated 7/6/16 at 8:00 PM revealed "...TF off until further notice...increased residual..."

Medical record review of an electronic Physicians Order dated 7/8/16 at 7:30 AM revealed "...nasogastric tube...withdraw...suction: clamped..."

Medical record review of a Surgery Progress note dated 7/8/16 at 12:58 PM revealed "...off ventilator...speech therapy to follow for swallowing, may need feeding tube in a few days if unable to swallow..."

Medical record review of a Speech Therapy consult dated 7/8/16 at 6:21 PM revealed "...pt. [patient] is not ready for a modified barium swallow study or for oral feedings...suggest alternative feedings..."

Medical record review of a Nurse's Note dated 7/8/16 at 11:41 PM revealed "...tubes: DHT...patent...inserted...position checked..."

Medical record review of the electronic Physicians Orders for 7/8/16 and 7/9/16 revealed no physicians order for the DHT.

Medical record review of an Abdominal KUB x-ray completed on 7/9/16 at 5:56 AM, and read by the Radiologist at 10:41 AM, revealed "...contrast noted within the colon...the feeding tube is not definitely seen on this exam..."

Medical record review of a Nurse's Note dated 7/9/16 at 9:00 AM revealed "...tube feed route interventions TF: DHT...10 ml/hr..."

Medical record review of a Nurse's Note dated 7/9/16 at 11:30 AM revealed "...TF discontinued...stopped d/t [due to] pt. c/o [compliants of] pain the abdomen..."

Medical record review of a Chest Decubitus x-ray (x-ray projection which is made with the patient lying on their side and the x-ray beam horizontal to the floor) dated 7/9/16 at 2:17 PM revealed "...status post feeding tube insertion which is unable to be followed beyond the cervical [neck] region..." Further review of an Addendum revealed "...the feeding tube extends into the right mainstem bronchus into the right pleural space with the distal tip located in the right costophrenic [rib and diaphragm area] angle..."

Medical record review of a Respiratory Therapy flowsheet dated 7/9/16 at 2:31 PM revealed "...O2 [oxygen] saturations 88% [normal 92-100% (percent)] on 4/lpm [liters per minute]...change O2 to 50% Venti-mask, pt. is mouth breathing...saturations came up to 93%..."

Medical record review of a Hospitalist Progress note dated 7/9/16 at 3:00 PM revealed "...pt. with abrupt changes in status after beginning TF...CXR [chest x-ray] repeated with apparent overload. Clinically he has developed tachycardia [elevated heart rate] of 144 he also complains of a lot of pain after tube feedings started per the DHT...the DHT not clearly seen on KUB but the weight tip is not seen in the chest. Repeat films ordered..."

Medical record review of a Surgery Progress note dated 7/9/16 at 3:50 PM revealed "...spoke with wife and daughters. Spoke with [named hospitalist]. Patient was doing well but has some generalized abdominal pain 4 hours ago...as soon as the tube feedings started pt. had acute onset abdominal pain, tachycardia [elevated heart rate], and tachypnea [elevated respiratory rate]...evaluation for gastric ulcer, pneumoperitoneum, pulmonary embolus..."

Medical record review of a CT [computerized tomography] scan of the chest dated 7/9/16 at 4:11 PM revealed "...status post feeding tube insertion which extends into the right mainstem bronchus peripherally into the right pleural space. The distal tip of the feeding tube is adjacent to the mid right lobe of the liver in what appears to be a subdiaphragmatic location...small pneumothorax [air in the lung] in the anterior inferior right hemothorax..."

Medical record review of a Hospitalist Progress note dated 7/9/16 at 5:10 PM revealed "...CT scan shows feeding tube in trach [trachea] and to the pleura area of the right lung. Discussed with the surgeon...will place a chest tube in the right side...pleural effusion present..."

Medical record review of a Procedure Note dated 7/9/16 at 6:18 PM revealed "...36 French Chest Tube...400 cc [cubic centimeters] turbid fluid..."

Medical record review of a Surgery Progress note dated 7/9/16 at 6:27 PM revealed "...CT reviewed...feeding tube went into lung out pt. lung into the pleural space. Most likely the tube did not enter the peritoneal cavity...spoke with [named cardiac thoracic surgeon] who was on-call...he suggested removing the DHT and placing a chest tube...I spoke with the family [wife, daughter] regarding the injury and the potential diagnoses and the need for a chest tube now...they want to transfer the pt. to [another hospital], I am agreeable but feel chest tube needs to be placed emergently so he does not develop a tension pneumothorax [progressive buildup of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space] during transfer..." Further review revealed "...chest tube placement went well..."

Medical record review of an Admission History and Physical from the receiving hospital on the day of the patient's transfer, 7/9/16, revealed "...was on the ventilator for 7 days...a swallowing study showed a delay in swallowing so a feeding tube was placed that went into his trachea and into the lung and chest cavity so a CT [chest tube] was placed at an outside hospital [Hospital B]..."

Medical record review of an Attending Physician note at the receiving hospital dated 7/11/16 at 10:48 AM [noted as late entry] revealed "...currently with pneumonitis secondary to transbronchial tube feed placement and insufflation of the tube feeds in the pleural cavity...he has a high risk for developing empyema [buildup of pus in the lungs] we will continue to maintain the chest tube..."

Review of facility documentation dated 7/8/16 revealed "...admitted with abdominal pain, distention and perforated viscus. On 7/8/16 at 11:49 PM a DHT was inserted into the patient's lung (instead of stomach)...KUB was ordered 5+ [plus] hours after placement. Tube feedings was started by oncoming day shift nurse. 2 hours into feeding, patient began to develop pain. It was determined at that time the DHT was not in the stomach and was actually in the lung. It was determined that the patient had a pneumothorax which required a chest tube. The patient was later transferred to another facility..."

Review of a letter, written by the Radiologist, dated 8/18/16 with no time, revealed "...a KUB was done the morning of 7/9/16 at 5:56 AM. I read and signed off on the KUB at 10:41 AM. Then the patient came down for a chest x-ray on the same day, 7/9/16 at 2:17 PM. I read and signed off on the chest x-ray at 4:13 PM. At this time I was unable to visualize the feed tube beyond the cervical region. Shortly thereafter, I spoke with [named surgeon] and said a CT scan would be more definitive. A CT scan was done at 4:11 PM and the film was read at 4:32 PM..."

Review of facility documentation with no date revealed "...patient had tube feeding started after Dobhoff [DHT] was placed without verification of placement. Upon insertion, the guidewire was removed before the DHT was completely advanced...nurse 1 placed DHT and there was a delay in placing order for KUB. Nurse 1 sat tube feedings up in patient's room. During hand-off, nurse 1 told nurse 2 that tube feeding was 'good to go'. Nurse 2 started tube feeding without reviewing x-ray results..."

Telephone interview with the patient's family on 8/29/16 at 9:45 AM revealed "...the nurses had tried to place a feeding tube but were unsuccessful...the night shift nurse told us...could pass a feeding tube in less than 30 seconds...he told us he had passed the tube the first attempt around 11:30 PM on 7/8/16...there was an x-ray machine right outside the door but they did not do the x-ray until 5:00 AM or 5:30 AM the next morning...they started the tube feedings around 8:30 or so on 7/9/16...when Physical Therapy came in to get him out of bed later, his blood pressure dropped, he became extremely short of breath and his oxygen saturations dropped...the doctor told me that the feeding tube was placed into his lung and that this lung was punctured...they put a chest tube in..."

Interview with RN #1 on 8/30/16 at 1:10 PM, in the conference room, revealed the nurse provided care for the patient on 7/9/16 during the dayshift. Further interview revealed "...the tube feedings were hanging in the patient's room but they were not infusing...his wife said they had changed the patient's formula...the feeding tube [DHT] was present when I went into the room...normally after a DHT placement we get a KUB to confirm placement...I was told the KUB had been done by the night shift nurse so I started the tube feedings around 9:00 AM...he did not complain of any pain at that time...about 2 hours after the feedings were infusing he complained of abdominal pain...there was some abdominal distention...later he started complaining of shortness of breath, his oxygen saturations dropped...I stopped the tube feedings and then called [named surgeon] and [named hospitalist]...a chest x-ray was ordered...the radiologist said they did not see the tip of the tube so they ordered a PA [posterior to anterior] chest x-ray to see if they could see it from the side view but they could not see it there...the patient continued to deteriorate so they ordered a CT scan of the abdomen...the patient had developed a pneumothorax and required a chest tube..."

Interview with the ICU Nurse Manager on 8/30/16 at 1:45 PM, in the conference room, revealed "...I found out about the feeding tube and the pneumothorax after the patient had left our facility...the ICU nurses were the only nurses in the facility who inserted the DHT feeding tubes at that time...the nurse who inserts the feeding tube is the one who should order the KUB...if the results are not back at the end of their shift, they should make that very clear to the oncoming nurse and the oncoming nurse should check that before starting the tube feedings...the night shift nurse set the tube feedings up in the room to have them ready to be started but the day shift nurse was the one who started it...she said that the night shift nurse had told her in report that everything was 'ready to go' so she thought that meant the KUB was confirmed...she started the tube feedings at 10 ml/hr..."

Interview with RN #2 on 8/30/16 at 2:50 PM, in the conference room, revealed the nurse worked the 7 PM-7 AM shift on 7/8/16. Further interview revealed "...the first time I tried the DHT it was unsuccessful because the patient kept coughing and did not tolerate it very well...I waited a few minutes then inserted the feeding tube...it only took about 45 seconds to do it...it was textbook easy...the KUB was not done until 5:00 AM...I did not start the tube feedings due to the KUB not being read on my shift...I told the day shift nurse the KUB had been completed and everything was ready to go...I had laid the tube feedings out...I had not received the radiology results before I left that morning..."

Interview with the Director of Quality Management on 8/30/16 at 3:05 PM, in the conference room, revealed "...we found out the tube was in the patient's lung on 7/9/16 once the x-ray was confirmed...the patient started having abdominal pain and coughing after the tube feedings were started...a chest x-ray was done and the patient had a CT scan which confirmed the feeding tube was in the patient's lung..."

Interview with the Director of Quality Management on 9/7/16 at 1:42 PM, in the conference room, revealed "...this happened on Saturday and the nurse came to me on Monday during our skills day and told me he had placed a feeding tube into a patient's lung and the tube feedings were started..." Further interview confirmed the feeding tube was inserted into the patient's right mainstem and pleural cavity and the tube feedings were initiated prior to confirmation of the feeding tube placement, which resulted in the patient's deterioration. Further interview confirmed the staff failed to ensure clear communication during the shift to shift handoff. Further interview confirmed the staff failed to follow the facility's policy/protocol.

Interview with the Chief Nursing Officer (CNO) on 9/8/16 at 4:55 PM, in the conference room, confirmed the feeding tube was inserted into the patient's lung and a pneumothorax was diagnosed. Further interview confirmed there was a delay in obtaining the confirmation x-ray for the tube feeding and the tube feedings were started prior to x-ray confirmation, which resulted in the patient's deterioration. Further interview confirmed the staff failed to follow the facility's policy.

Based on review of facility policy, review of facility documentation, medical record review, and interview, the facility failed to ensure a physician's order for a Dobhoff feeding tube (DHT) was obtained for 1 patient (#1) of 4 patients reviewed.

The findings included:

Review of facility policy Telephone-Verbal Order Policy, with a revision date of 2/23/16 revealed "...the entire verbal order will be entered in to the electronic record [EHR] by entering the provider name into the Physician name field and selecting the communication type...Verbal Order with Read Back...if the electronic health record is not available: the entire verbal order will be written down and read back to the person transmitting the order for confirmation..."

Medical record review revealed Patient #1 was admitted to Hospital B on 7/1/16 with diagnoses including Sepsis Secondary to Peritonitis secondary to perforated viscus and three day status post Left Hip Arthroplasty (hip replacement). Further review revealed the patient was transferred to another acute care hospital on 7/9/16.

Medical record review of an electronic Physicians order dated 7/1/16 at 5:50 PM revealed "...nasogastric tube...suction, low intermittent..."

Medical record review of an electronic Physicians Order dated 7/8/16 at 7:30 AM revealed "...nasogastric tube...withdraw..."

Medical record review of a Nurse's Note dated 7/8/16 at 11:41 PM revealed "...tubes: DHT...patent...inserted...position checked..."

Medical record review of a Nurse's Note dated 7/9/16 at 11:30 AM revealed "...TF discontinued...stopped d/t [due to] pt. c/o pain the abdomen..."

Medical record review of the physicians orders for 7/8/16 or 7/9/16 revealed no physicians order for the DHT.

Review of an Investigation Summary Worksheet dated 7/8/16 revealed "...no order could be found to place the DHT..." Further review revealed "...nurse could not recall the exact order for the feeding tube..."

Interview with the Director of Quality Management on 9/7/16 at 1:42 PM, in the conference room, confirmed "...we could not find a physician's order for the DHT...I think they have been using the previous NGT order or the nurse may have talked to the physician and failed to put the order in the computer..." Further interview revealed "...there should have been a physician's order for the DHT..."