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Based on findings from document review and interviews, the medical care provided to Patient A did not meet generally accepted standards of medical practice. Specifically, when the patient presented to the emergency department (ED) for replacement of a gastrostomy feeding tube (G-tube), the ED Attending Physician (Physician #1) failed to perform an adequate assessment of the patient's abdomen and erroneously inserted the G-tube into the patient's umbilicus.

Findings include:

--Review of two MRs for Patient A reveals the following information: On 05/17/13 at 22:45, this patient, a developmentally disabled female, presented to the ED from the long term care facility where she resided, for replacement of her G-tube after pulling it out that evening. Patient A's history included aspiration of liquids and dependence on gastrostomy feedings. Physician #1 evaluated the patient and noted that the examination of the patient's abdomen was unremarkable. At 22:53 Physician #1 documented the insertion of a 20 French gastrostomy tube and confirmation of tube placement with aspiration of the gastric contents. Physician #1 documented minimal difficulty with placement of the tube and that the patient tolerated the procedure well. Patient A was discharged back to the long term care facility at 22:50.

The following morning, on 05/18/13 at 08:49, Patient A presented back to the ED with a chief complaint of abdominal pain. ED nursing staff documented that the patient's G-tube had been replaced the previous day, that the tube was in her umbilicus and that the patient moaned and grimaced when her abdomen was palpated. An Abdominal/Pelvic CT scan was obtained which showed a large amount of free intraperitoneal air, that the previous G-tube had been removed or dislodged, and that a new G-tube was at the level of the umbilicus and did not appear to be within the lumen of the stomach or bowel. Patient A was treated with Morphine and Cephazolin and Physician #2 documented a clinical impression of peritonitis. At 12:46, the patient was transferred to a higher level of care at another hospital by ambulance.

--Per interview with Physician #1 on 06/12/13 at 08:15, he/she did not completely visualize the patient's abdomen prior to insertion of the G-tube and did not see the previous stoma. Physician #1 thought that the patient's umbilicus was the patient's stoma and acknowledged mistakenly placing the G-tube in Patient A's umbilicus at the time of her ED visit on 05/17/13.