HospitalInspections.org

Based on observations, interviews, and document review, it was determined the facility staff failed to obtain an order for the insertion of a nasogastric tube, and properly document the size and person who placed the nasogastric tube as per facility policy for two (2) of three (3) patients sampled.

Findings:

A review of the emergency department (ED) provider note for Patient #4 (P4) from 9/8/2023 at 6:17 p.m. contained documentation that the on-call surgeon "recommended placement of a NG tube," and at 6:30 p.m. the documentation "Nursing staff to place NG tube," and then "KUB (abdominal kidney, ureter, bladder x-ray)ordered for NG placement."

A review of the Event Log contained the documentation on 9/8/2023 at 8:00 p.m. "... NG/OG Tub Nasogastric: Left nostril Placed ... Tube Type: Nasogastric. Tube Location: Left nostril. Catheter Depth (cm): 60 cm. Placement Verification Method: X-ray. Securing Method: Tape ..." No documentation of the size NG tube inserted, as per the facility's policy.

A review of the medical record for P4 contained no evidence of a physician's order for a nasogastric tube placed in the emergency department on 9/8/2023 at 8:00 p.m.

A review of the medical record for P6 contained no evidence of a physician's order for a nasogastric (NG) tube placed in the emergency department. There was a provider note stating that the NG tube had been placed in the emergency department. There was no note to indicate who placed the NG tube.

SM1 was aware of the lack of orders for P4 and P6 above.

A review of the facility's policy titled "Medical Orders for Patient Care" states in part:
... Policy:
... B. Orders shall be:
1. Obtained prior to performing all procedures and/or treatments;
2. Documented in a patient's electronic health record (EHR).
3. Dated, timed and signed by the ordering Practitioner or another Practitioner who is responsible for the care of the patient only if such provider is acting in accordance with Virginia law, facility policies, and the Medical Staff Bylaws.
4. Dated and time stamped electronically by the electronic health record (EHR) system;
5. Acknowledged and verified by appropriate licensed Team Members (when indicated).
6. Implemented promptly and within the timeframe specified.
... Appendix A
... #7 Verbal with Read Back (Verbal Orders)
Verbal Orders must be relayed by the ordering Practitioner, either in person or by telephone, to an Authorized Person. Verbal Orders must be cosigned promptly by the Practitioner no more than [seventy-two] 72 hours after the order is entered.
Verbal Orders are to be used infrequently ...

A review of the facility's policy titled "Lippincott Procedures: Nasogastric or Orogastric Tube Insertion" states in part:
... A practitioner selects the type and diameter of NG or OG tube that best meets the patient's needs.
... Implementation
Verify the practitioner's order.
... Documentation
Documentation associated with NG or OG tube insertion includes: type and size of the NG or OG tube, date and, time of insertion, insertion route, tube's external length measurement and centimeter mark, methods used to confirm tube placement, type and amount of suction (if used), drainage: amount, color, character, consistency, odor, patient's tolerance of the procedure, signs and symptoms of complications: nausea, vomiting, abdominal distention ...

The above concerns were discussed at the exit conference on 12/13/2023.