HospitalInspections.org

Based on medical record review and interview, the facility failed to document insertion of a feeding tube for one patient (#1) of five sampled patients.

The findings included:

Patient #1 was admitted to the facility on July 12, 2012, with diagnoses including Acute Respiratory Failure and Dysphagia.

Medical record review of a physician's order dated July 16, 2012, at 9:22 a.m., revealed, "...Place Dobbhoff (feeding tube) tube at bedside. Confirm feeding tube tip in the stomach or duodenum..."

Medical record review of an abdominal x-ray report dated July 16, 2012, revealed, "...nasoenteric feeding tube coiled over the lower left chest...virtually certainly in the left pleural space with perforation of the left lung...Follow up chest radiography is strongly recommended..."

Medical record review of a chest x-ray report dated July 16, 2012, revealed, "...Mal-placed nasoenteric tube remains in place to the left pleural space...No perceptible pneumothorax currently..."

Medical record review of a physician progress note dated July 17, 2012, at 12:01 p.m., revealed, "...Pneumothorax after bedside attempt of tube feeding placement..."

Medical record review revealed no documentation regarding insertion of the feeding tube.

Telephone interview with the Chief Nursing Officer on September 11, 2013, at 2:30 p.m., confirmed a registered nurse was responsible for the insertion of a feeding tube and the facility failed to ensure documentation of the procedure in the medical record.

C/O: #32356