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Based on policy and procedure review, skills competency checklist review, medical record review, staff and physician interviews, incident log review and personnel file review, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to receive care in a safe setting; failed to maintain an organized and effective quality assessment and improvement program; and failed to ensure an effective nursing service to provide supervision and evaluation of patient care.

The findings include:

1. Hospital nursing staff failed to provide a safe environment for 1 of 1 patients receiving a Dobhoff nasogastric small bore feeding tube (Patient #16). Hospital staff allowed a Registered Nurse (RN #1) who had not demonstrated competency for insertion and removal of a Dobhoff nasogastric feeding tube to insert and remove a Dobhoff nasogastric small bore feeding tube. The nurse failed to follow the hospital's policy for removal of the Dobhoff nasogastric feeding tube by failing to notify a physician of the position of the Dobhoff nasogastric feeding tube prior to removal. The patient developed a pneumothorax after the removal of the Dobhoff nasogastric feeding tube and subsequently expired.

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

2. Hospital staff failed to ensure tracking of patient safety events by failing to document, investigate and complete an incident report for 1 of 1 sampled patients (Patient #16) with insertion and removal of a Dobhoff Nasogastric tube (small bore feeding tube).

~cross refer to 482.21 Quality Assessment and Performance Improvement: Tag 0286

3. Hospital nursing staff failed to supervise and ensure trained and competent nursing staff inserted and removed Dobhoff nasogastric small bore feeding tubes according to hospital policy for 1 of 1 patients receiving a Dobhoff nasogastric small bore feeding tube (Patient #16). Hospital staff allowed a Registered Nurse (RN #1) who had not demonstrated competency for insertion and removal of a Dobhoff nasogastric feeding tube to insert and remove a Dobhoff nasogastric feeding tube. The nurse failed to follow the hospital's policy for removal of the Dobhoff nasogastric feeding tube by failing to notify a physician of the position of the Dobhoff nasogastric feeding tube prior to removal. The patient developed a pneumothorax after the removal of the Dobhoff nasogastric feeding tube and subsequently expired.

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

4. Nursing staff failed to follow the hospital's policy by inserting and/or removing a feeding tube without an LIP (Licensed Independent Practitioner) order for 2 of 6 patient sampled patients receiving a feeding tube (Patient #16 and #20).

~cross refer to 482.23 (b)(6) Nursing Services Standard: Supervision of Contract Staff, Tag A0398

Based on policy and procedure review, skills competency checklist review, medical record review, staff and physician interviews, and personnel file review, hospital staff failed to protect and promote patients' rights by failing to ensure nursing staff were trained, competent, and followed the hospital's policy and procedure for insertion and removal of Dobhoff small bore nasogastric feeding tubes prior to insertion.

The findings include:

Hospital nursing staff failed to provide a safe environment for 1 of 1 patients receiving a Dobhoff nasogastric small bore feeding tube (Patient #16). Hospital staff allowed a Registered Nurse (RN #1) who had not demonstrated competency for insertion and removal of a Dobhoff nasogastric feeding tube to insert and remove a Dobhoff nasogastric small bore feeding tube. The nurse failed to follow the hospital's policy for removal of the Dobhoff nasogastric feeding tube by failing to notify a physician of the position of the Dobhoff nasogastric feeding tube prior to removal. The patient developed a pneumothorax after the removal of the Dobhoff nasogastric feeding tube and subsequently expired.

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

Based on policy and procedure review, skills competency checklist review, medical record reviews, staff and physician interviews, and personnel file review, hospital staff failed to provide a safe environment for 1 of 1 patients receiving a Dobhoff Nasogastric small bore feeding tube (Patient #16). Hospital staff allowed a Registered Nurse (RN #1) who had not demonstrated competency for insertion and removal of a Dobhoff Nasogastric feeding tube to insert and remove a Dobhoff Nasogastric feeding tube. The nurse failed to follow the hospital's policy for removal of the Dobhoff Nasogastric feeding tube by failing to notify a physician of the position of the Dobhoff Nasogastric feeding tube prior to removal. The patient developed a pneumothorax after the removal of the Dobhoff Nasogastric feeding tube and subsequently expired.

The findings include:

Review of policy titled "Nasogastric Tube Insertion and Nasogastric Tube Insertion and Enteral Nutritional Support for Adults" with effective date of 08/30/2021, revealed PURPOSE: To provide guidelines for nasogastric tube insertion and best practice guidelines for management of patient receiving enteral feeding. ... See Attached Competencies: Dobhoff (Small Bore) Feeding Tube Competency. ... (Type of Feeding Tube) Nasogastric small bore (Dobhoff) feeding tube with stylet (Where the Tube is Inserted) Special type of NG tube which is more flexible and comfortable for the patient. Inserted by the use of a stylet (Gguide wire) which is removed after correct placement is confirmed. ..."

Review of the attached RN Competency revealed, "Compentency: Small Bore Feeding Tube Insertion Competency (Dobhoff) Insertion to be preformed by a Clinical Educator, Resource Nurse/Charge Nurse. If unavailable, a RN with documented competency can perform insertion. ... PROCEDURE: Verify LIP (Licensed Independent Practitioner) order .... If tube is in airway on x-ray, notify LIP prior to removing tube. A pneumothorax could result upon removal of a tube that has been placed in the airway ... "

Closed medical record review of Patient #16 revealed a 80 year old female admitted on 11/17/2021 for Pneumonia. Review of a Hospitalist (physician) note dated 11/17/2021 at 0633 revealed a past medical history of anemia, dementia, and on home oxygen therapy. Review revealed Patient #16 was a resident of a nursing home who presented with shortness of breath. Review of a nurses note documented by RN #1 on 11/20/2021 at 1956 revealed "Patient is confused and speaks incoherently during interactions with this nurse. Orders for NGT (Nasogastric tube) were place (sic) and a 10 french dobhoff was measured and inserted in the R (right) nare. The NGT began leaking a (sic) orange tinged fluid that drained into a chux (disposable absorbent incontinent cloth) pad. Upon final xray impression by radiologist, it was determined NGT was in the base of the L (left) left (sic). NGT was removed and the drainage from NGT measured approximately 200 ml (milliliters). Patient SpO2 (oxygen saturation) was at 92%." Review of Abdominal xray report dated 11/20/2021 at 1913 revealed "Feeding tube projects very lateral in the left upper abdomen lower lung base unknown location possibly left lower lobe. Does not project in the area of the stomach. IMPRESSION: Feeding tube very lateral towards the left lung base upright abdomen could not exclude this being within the lung base does not project in the area of the stomach. Report telephoned to nurse (RN #1) at time of dictation." Review of the medical record revealed Patient #16 was diagnosed with a pneumothorax after Dobhoff removal of the NGT by RN #1. Review of Chest xray dated 11/20/2021 at 2042 revealed "Findings: Interval appearance of large left-sided pneumothorax with some displacement of the central mediastinal structures towards the right. Persistent infiltrate throughout the right lung. IMPRESSION: Interval appearance of large left-sided pneumothorax with a degree of mediastinal shift, telephoned to nurse Maria, before the dictation...." Review of MD #4's note written on 11/20/2021 at 2045 revealed "...seen at the bedside was in acute respiratory distress and hypoxic respiratory failure and obtunded. Patient was placed on BIPAP 20/12. Respiratory status did not improve. Stat chest xray is ordered with a left pneumothorax with midline shift to the right and completely effaced/white lesion of the right lung." Review of MD #5's note written on 11/20/2021 at 2051 revealed "Emergency decompression of pneumothorax in patient with severe hypoxemia (Sp02 in the 60s, tachypneic, obtunded) and severe bilateral lung parenchymal disease. Considered emergent procedure..." Review revealed an emergent chest tube was inserted by MD #5 on 11/20/2021 at 2051. Patient #16 was moved to ICU (Intensive Care Unit) for monitoring. Further review of the medical record revealed Patient #16 expired on 11/21/2021 at 0320.

Interview on 02/23/2022 at 1445 with NP #8 revealed the nurse practitioner remembered Patient #16. Interview revealed no phone call from the nurse was received prior to the end of the shift regarding the lung placement of the Dobhoff tube. Interview revealed a physician should have been at bedside before the tube was removed. Interview revealed the policy was not followed.

Telephone interview on 02/24/2022 at 0920 with MD #4 revealed he was the Hospitalist that responded to a call received on 11/20/2021 from a nurse who reported that Patient #16 was having worsening respiratory distress. MD #4 stated the nurse reported that the patient was requiring increased oxygen and having mental status changes. The physician stated that when he arrived respiratory staff was already there and he called a rapid response nurse for assistance. MD #4 reported that Patient #16 was obtunded (diminished responsiveness to stimuli) and in respiratory distress upon his arrival. He stated he was told that an NGT was placed, followed by a bedside x-ray that showed the tube was in the patient's lung. MD #4 reported he was told the NGT was pulled out and the patient was having respiratory distress. He reported he ordered a stat chest x-ray which showed the patient had a pneumothorax. MD #4 stated he should have been notified of the placement of the NGT in the patient's lung. The physician stated that if he was notified of the incorrect placement, he would have been at the bedside when the NGT was removed due to the complication of a pneumothorax when the tube was removed.

Telephone interview on 02/24/2022 at 1110 with MD #5 revealed he was the ICU attending physician who was on call on 11/20/2021 and he remembered Patient #16. The physician stated he received a phone call from MD #4 who said he needed a chest tube insertion for the patient that had developed a pneumothorax after an NGT was removed. MD #5 stated that Patient #16 was "ready to code" upon his arrival. MD #5 reported he inserted a chest tube and the patient was moved to the ICU. The physician stated the patient continued to deteriorate. He reported that after discussion with the patient's family, the patient was placed on comfort care and died on 11/21/2021 at 0320.

Interview with RN #1 was requested on 02/22/2022. Interview was not obtained due to RN #1 was no longer employed at the facility.

Review of personnel file of RN #1 revealed a hire date of 06/10/2019 as a Nurse Extern with a new title of Nursing Assistant II on 07/19/2020. Review revealed a change of title for RN #1 of Staff Nurse on 09/13/2020. Review revealed no evidence of competencies or validation for skills with the Dobhoff small bore feeding tube insertion or removal. Review revealed RN #1 resigned on 12/18/2021.

Interview on 02/24/2022 at 1410 with CNO #6 revealed RN #1 had not demonstrated competencies to insert and remove Dobhoff nasogastric small bore feeding tubes. Interview revealed RN #1 was not certified to insert and remove Dobhoff tubes.

Interview on 02/24/2022 at 1610 with PCM (Patient Care Manger) #3 revealed RN #1 was not listed on the roster of the Dobhoff tube training in August 2021. Interview revealed PCM #3 was unsure the reason RN #1 did not attend the training for the Dobhoff tube insertion and removal. PCM #3 revealed the responsibility of training staff is PCM's responsibility.

Based on review of policy, incident report log, and interviews with staff, the facility staff failed to ensure tracking of patient safety events by failing to document, investigate and complete an incident report for 1 of 1 sampled patients (Patient #16) with insertion and removal of a Dobhoff Nasogastric tube (small bore feeding tube).

The findings include:

Review of a policy titled "SIR (Safety Improvement Report) Reporting/Review Team Process" with effective date of 01/13/2020 revealed "Purpose: To provide a standardized process for evaluating, reviewing and categorizing reported data as a part of the peer review process to determine if there are 'patterns over time' for the purpose of: Improving management of patient care and services, by providing intervention for patient safety and prevention of occurrences. Providing a database for care/services that is analyzed, evaluated and acted upon...SIRs are a significant part of the Quality and Patient Safety Program. They are records produced at the direction of and for consideration by the MEC (Medical Executive Committee) through the Quality Council/Patient Safety Team....(Hospital) employees, leaders and medical staff members are responsible for abiding by the procedures and respective policies regarding the reporting of occurrences and sentinel events that occur or have the potential to occur within the organization. The culture of our organization is to create and maintain an environment in which the staff, leadership, medical staff members, patients and visitors can identify and notify individuals when a near miss, occurrence or sentinel event has occurred. The (named hospital) culture is one of accountability that does not focus on the human error or the unintended consequences, but rather on the quality of the decisions made. WHO SHOULD REPORT: 1. Health System personnel and medical staff are responsible for completing SIR reports. 2. When an event occurs or is identified, a SIR is completed by the staff member most closely associated with the event. 3. In cases where an event directly involves more than one department, the report is completed by the department staff when the event occurred. 4. The follow-up is completed by the department where the event occurred...."

Closed medical record review on 02/23/2022 of Patient #16 revealed a 80 year old female admitted on 11/17/2021 for Pneumonia. Review of a Hospitalist (physician) note dated 11/17/2021 at 0633 revealed a past medical history of anemia, dementia, and on home oxygen therapy. Review revealed Patient #16 was a resident of a nursing home who presented with shortness of breath. Review of a nurses note documented by RN #1 on 11/20/2021 at 1956 revealed "Patient is confused and speaks incoherently during interactions with this nurse. Orders for NGT (Nasogastric tube) were place (sic) and a 10 french dobhoff was measured and inserted in the R (right) nare. The NGT began leaking a (sic) orange tinged fluid that drained into a chux (disposable absorbent incontinent cloth) pad. Upon final xray impression by radiologist, it was determined NGT was in the base of the L (left) left (sic). NGT was removed and the drainage from NGT measured approximately 200 ml (milliliters). Patient SpO2 (oxygen saturation) was at 92%." Review of the medical record revealed Patient #16 was diagnosed with a pneumothorax after Dobhoff removal by RN #1. Review of MD #4's note written on 11/20/2021 at 2045 revealed "...Stat chest xray is ordered with a left pneumothorax with midline shift to the right and completely effaced/white lesion of the right lung." Review of MD #5's note written on 11/20/2021 at 2051 revealed "Emergency decompression of pneumothorax in patient with severe hypoxemia (Sp02 in the 60s, tachypneic - rapid breathing, obtunded) and severe bilateral lung parenchymal disease (progressive scarring of lung tissue). Considered emergent procedure..." Further review of the medical record revealed Patient #16 expired on 11/21/2021 at 0325.

Review of the hospital's incident log revealed no incident report was found regarding the incorrrect placement of the Dobhoff nasogastric small bore feeding tube for Patient #16.

Interview on 02/23/2022 at 1341 with Radiologist #7 revealed the NG tube was seen in the lung base of Patient #16. Interview revealed the findings were called to RN #1. Interview revealed the incident report was the nurses responsibility to complete.

Interview with RN #1 was requested on 02/22/2022. RN #1 was not available for interview due to RN #1 was no longer employed at the facility.

Interview on 02/23/2022 at 1555 with RN #9 revealed she was the oncoming nurse providing care to Patient #16 on 11/20/2021. The nurse stated the NG tube had been removed before the night shift had begun. Interview revealed RN #1 should have written the incident report of the NG tube in the lung.

Interview on 02/23/2022 at 1050 with PCM #3 revealed no incident report was written and no investigation was conducted. Interview revealed no action was taken to prevent reoccurrence. Interview revealed the hospital's policy was not followed to complete an incident report.

Based on policy and procedure review, skills competency checklist review, medical record reviews, staff and physician interviews, and personnel file review, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to patients requiring nasogastric feeding tube insertion and removal.

The findings include:

1. Hospital nursing staff failed to supervise and ensure trained and competent nursing staff inserted and removed Dobhoff nasogastric small bore feeding tubes according to hospital policy for 1 of 1 patients receiving a Dobhoff nasogastric small bore feeding tube (Patient #16). Hospital staff allowed a Registered Nurse (RN #1) who had not demonstrated competency for insertion and removal of a Dobhoff nasogastric feeding tube to insert and remove a Dobhoff nasogastric feeding tube. The nurse failed to follow the hospital's policy for removal of the Dobhoff nasogastric feeding tube by failing to notify a physician of the position of the Dobhoff nasogastric feeding tube prior to removal. The patient developed a pneumothorax after the removal of the Dobhoff nasogastric feeding tube and subsequently expired.

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

2. Nursing staff failed to follow the facility policy by inserting and/or removing a feeding tube without an LIP (Licensed Independent Practitioner) order for 2 of 6 patient records reviewed. (Patient #16 and #20).

~cross refer to 482.23 (b)(6) Nursing Services Standard: Supervision of Contract Staff, Tag A0398

Based on policy and procedure review, skills competency checklist review, medical record reviews, staff and physician interviews, and personnel file review, hospital nursing staff failed to supervise and ensure trained and competent nursing staff inserted and removed Dobhoff nasogastric small bore feeding tubes according to hospital policy for 1 of 1 patients receiving a Dobhoff nasogastric small bore feeding tube (Patient #16). Hospital staff allowed a Registered Nurse (RN #1) who had not demonstrated competency for insertion and removal of a Dobhoff nasogastric feeding tube to insert and remove a Dobhoff nasogastric feeding tube. The nurse failed to follow the hospital's policy for removal of the Dobhoff nasogastric feeding tube by failing to notify a physician of the position of the Dobhoff nasogastric feeding tube prior to removal. The patient developed a pneumothorax after the removal of the Dobhoff nasogastric feeding tube and subsequently expired.

The findings include:

Review of policy titled "Nasogastric Tube Insertion and Nasogastric Tube Insertion and Enteral Nutritional Support for Adults" with effective date of 08/30/2021, revealed PURPOSE: To provide guidelines for nasogastric tube insertion and best practice guidelines for management of patient receiving enteral feeding. ... See Attached Competencies: Dobhoff (Small Bore) Feeding Tube Competency. ... (Type of Feeding Tube) Nasogastric small bore (Dobhoff) feeding tube with stylet (Where the Tube is Inserted) Special type of NG tube which is more flexible and comfortable for the patient. Inserted by the use of a stylet (Gguide wire) which is removed after correct placement is confirmed. ..."

Review of the attached RN Competency revealed, "Compentency: Small Bore Feeding Tube Insertion Competency (Dobhoff) Insertion to be performed by a Clinical Educator, Resource Nurse/Charge Nurse. If unavailable, a RN with documented competency can perform insertion. ... PROCEDURE: Verify LIP (Licensed Independent Practitioner) order .... If tube is in airway on x-ray, notify LIP prior to removing tube. A pneumothorax could result upon removal of a tube that has been placed in the airway ... "

Closed medical record review of Patient #16 revealed a 80 year old female admitted on 11/17/2021 for Pneumonia. Review of a Hospitalist (physician) note dated 11/17/2021 at 0633 revealed a past medical history of anemia, dementia, and on home oxygen therapy. Review revealed Patient #16 was a resident of a nursing home who presented with shortness of breath. Review of a nurses note documented by RN #1 on 11/20/2021 at 1956 revealed "Patient is confused and speaks incoherently during interactions with this nurse. Orders for NGT (Nasogastric tube) were place (sic) and a 10 french dobhoff was measured and inserted in the R (right) nare. The NGT began leaking a (sic) orange tinged fluid that drained into a chux (disposable absorbent incontinent cloth) pad. Upon final xray impression by radiologist, it was determined NGT was in the base of the L (left) left (sic). NGT was removed and the drainage from NGT measured approximately 200 ml (milliliters). Patient SpO2 (oxygen saturation) was at 92%." Review of Abdominal xray report dated 11/20/2021 at 1913 revealed "Feeding tube projects very lateral in the left upper abdomen lower lung base unknown location possibly left lower lobe. Done not project in the area of the stomach. IMPRESSION: Feeding tube very lateral towards the left lung base upright abdomen could not exclude this being within the lung base does not project in the area of the stomach. Report telephoned to nurse (RN #1) at time of dictation." Review of the medical record revealed Patient #16 was diagnosed with a pneumothorax after Dobhoff removal of the NGT by RN #1. Review of Chest xray dated 11/20/2021 at 2042 revealed "Findings: Interval appearance of large left-sided pneumothorax with some displacement of the central mediastinal structures towards the right. Persistent infiltrate throughout the right lung. IMPRESSION: Interval appearance of large left-sided pneumothorax with a degree of mediastinal shift, telephoned to nurse Maria, before the dictation...."Review of MD #4's note written on 11/20/2021 at 2045 revealed "...seen at the bedside was in acute respiratory distress and hypoxic respiratory failure and obtunded. Patient was placed on BIPAP 20/12. Respiratory status did not improve. Stat chest xray is ordered with a left pneumothorax with midline shift to the right and completely effaced/white lesion of the right lung." Review of MD #5's note written on 11/20/2021 at 2051 revealed "Emergency decompression of pneumothorax in patient with severe hypoxemia (Sp02 in the 60s, tachypneic, obtunded) and severe bilateral lung parenchymal disease. Considered emergent procedure..." Review revealed an emergent chest tube was inserted by MD #5 on 11/20/2021 at 2051. Patient #16 was moved to ICU (Intensive Care Unit) for monitoring. Further review of the medical record revealed Patient #16 expired on 11/21/2021 at 0320.

Interview on 02/23/2022 at 1445 with NP #8 revealed the nurse practitioner remembered Patient #16. Interview revealed no phone call from the day nurse was received prior to the end of the shift regarding the lung placement of the Dobhoff tube. Interview revealed a physician should have been at bedside before the tube was removed. Interview revealed the policy was not followed.

Telephone interview on 02/24/2022 at 0920 with MD #4 revealed he was the hospitalist that responded to a call received on 11/20/2021 from a nurse who reported that Patient #16 was having worsening respiratory distress. MD #4 stated the nurse reported that the patient was requiring increased oxygen and having mental status changes. The physician stated that when he arrived respiratory staff was already there and he called a rapid response nurse for assistance. MD #4 reported that Patient #16 was obtunded and in respiratory distress upon his arrival. He stated he was told that an NGT was placed, followed by a bedside x-ray that showed the tube was in the patient's lung. MD #4 reported he was told the NGT was pulled out and the patient was having respiratory distress. He reported he ordered a stat chest x-ray which showed the patient had a pneumothorax. MD #4 stated he should have been notified of the placement of the NGT in the patient's lung. The physician stated that if he was notified of the incorrect placement, he would have been at the bedside when the NGT was removed due to the complication of a pneumothorax when the tube was removed.

Telephone interview on 02/24/2022 at 1110 with MD #5 revealed he was the ICU attending physician who was on call on 11/20/2021 and he remember Patient #16. The physician stated he received a phone call from MD #4 who said he needed a chest tube insertion for the patient that had developed a pneumothorax after an NGT was removed. MD #5 stated that Patient #16 was "ready to code" upon his arrival. MD #5 reported he inserted a chest tube and the patient was moved to the ICU. The physician stated the patient continued to deteriorate. He reported that after discussion with the patient's family, the patient was placed on comfort care and died on 11/21/2021 at 0320.

Interview with RN #1 was requested on 02/22/2022. Interview was not obtained due to RN #1 was no longer employed at the facility.

Review of personnel file of RN #1 revealed a hire date of 06/10/2019 as a Nurse Extern with a new title of Nursing Assistant II on 07/19/2020. Review revealed a change of title for RN #1 of Staff Nurse on 09/13/2020. Review revealed no evidence of competencies or validation for skills with the Dobhoff small bore feeding tube insertion or removal. Review revealed RN #1 resigned on 12/18/2021.

Interview on 02/24/2022 at 1410 with CNO #6 revealed RN #1 had not demonstrated competencies to insert and remove Dobhoff nasogastric small bore feeding tubes. Interview revealed RN #1 was not certified to insert and remove Dobhoff tubes.

Interview on 02/24/2022 at 1610 with PCM (Patient Care Manger) #3 revealed RN #1 was not listed on the roster of the Dobhoff tube training in August 2021. Interview revealed PCM #3 was unsure the reason RN #1 did not attend the training for the Dobhoff tube insertion and removal. PCM #3 revealed the responsibility of training staff is PCM's responsibility.

Based on facility policy review, medical record review, staff feeding tube competency review, personnel file review and staff and physician interview, nursing staff failed to follow the hospital's policy by inserting and/or removing a feeding tube without an LIP (Licensed Independent Practitioner) order for 2 of 6 sampled patients that received a feeding tube (Patient #16 and #20).

The findings include:

Review of policy titled "Nasogastric Tube Insertion and Nasogastric Tube Insertion and Enteral Nutritional Support for Adults" with effective date of 08/30/2021, revealed PURPOSE: To provide guidelines for nasogastric tube insertion and best practice guidelines for management of patient receiving enteral feeding. ... See Attached Competencies: Dobhoff (Small Bore) Feeding Tube Competency. ... (Type of Feeding Tube) Nasogastric small bore (Dobhoff) feeding tube with stylet (Where the Tube is Inserted) Special type of NG tube which is more flexible and comfortable for the patient. Inserted by the use of a stylet (Gguide wire) which is removed after correct placement is confirmed. ..."

Review of the attached RN Competency revealed, "Compentency: Small Bore Feeding Tube Insertion Competency (Dobhoff) Insertion to be performed by a Clinical Educator, Resource Nurse/Charge Nurse. If unavailable, a RN with documented competency can perform insertion. ... PROCEDURE: Verify LIP (Licensed Independent Practitioner) order .... If tube is in airway on x-ray, notify LIP prior to removing tube. A pneumothorax could result upon removal of a tube that has been placed in the airway ... "

1. Closed medical record review of Patient #16 revealed a 80 year old female admitted on 11/17/2021 for Pneumonia. Review of a Hospitalist (physician) note dated 11/17/2021 at 0633 revealed a past medical history of anemia, dementia, and on home oxygen therapy. Review revealed Patient #16 was a resident of a nursing home who presented with shortness of breath. Review of a nurses note documented by RN #1 on 11/20/2021 at 1956 revealed "Patient is confused and speaks incoherently during interactions with this nurse. Orders for NGT (Nasogastric tube) were place (sic) and a 10 french dobhoff was measured and inserted in the R (right) nare. The NGT began leaking a (sic) orange tinged fluid that drained into a chux (disposable absorbent incontinent cloth) pad. Upon final xray impression by radiologist, it was determined NGT was in the base of the L (left) left (sic). NGT was removed and the drainage from NGT measured approximately 200 ml (milliliters). Patient SpO2 (oxygen saturation) was at 92%." Review of Abdominal xray report dated 11/20/2021 at 1913 revealed "Feeding tube projects very lateral in the left upper abdomen lower lung base unknown location possibly left lower lobe. Done not project in the area of the stomach. IMPRESSION: Feeding tube very lateral towards the left lung base upright abdomen could not exclude this being within the lung base does not project in the area of the stomach. Report telephoned to nurse (RN #1) at time of dictation." Review of the medical record revealed Patient #16 was diagnosed with a pneumothorax after Dobhoff removal of the NGT by RN #1. Review of Chest xray dated 11/20/2021 at 2042 revealed "Findings: Interval appearance of large left-sided pneumothorax with some displacement of the central mediastinal structures towards the right. Persistent infiltrate throughout the right lung. IMPRESSION: Interval appearance of large left-sided pneumothorax with a degree of mediastinal shift, telephoned to nurse Maria, before the dictation...."Review of MD #4's note written on 11/20/2021 at 2045 revealed "...seen at the bedside was in acute respiratory distress and hypoxic respiratory failure and obtunded. Patient was placed on BIPAP 20/12. Respiratory status did not improve. Stat chest xray is ordered with a left pneumothorax with midline shift to the right and completely effaced/white lesion of the right lung." Review of MD #5's note written on 11/20/2021 at 2051 revealed "Emergency decompression of pneumothorax in patient with severe hypoxemia (Sp02 in the 60s, tachypneic, obtunded) and severe bilateral lung parenchymal disease. Considered emergent procedure..." Review revealed an emergent chest tube was inserted by MD #5 on 11/20/2021 at 2051. Patient #16 was moved to ICU (Intensive Care Unit) for monitoring. Further review of the medical record revealed Patient #16 expired on 11/21/2021 at 0320.

Review of the medical record revealed an order for the NG tube on 11/19/2021 at 1348. Review of the medical record revealed no written order for the Dobhoff nasogastric small bore feeding tube. Review of medical record of Patient #16 failed to reveal a notification of the LIP prior to removing the Dobhoff nasogastric tube from the lungs.

Interview on 02/23/2022 at 1510 with MD #2 revealed the need for a Doboff (small bore feeding tube) was discussed in rounds by the physicians. Interview confirmed the order for the Dobhoff tube was never placed in the computer. Interview revealed the order for the tube was not found in Patient #16's chart. Interview revealed no notes of RN #1 contacting the LIP prior to removing the Dobhoff.

Telephone interview on 02/24/2022 at 0920 with MD #4 revealed he was the hospitalist that responded to a call received on 11/20/2021 from a nurse who reported that Patient #16 was having worsening respiratory distress. MD #4 stated the nurse reported that the patient was requiring increased oxygen and having mental status changes. The physician stated that when he arrived respiratory staff was already there and he called a rapid response nurse for assistance. MD #4 reported that Patient #16 was obtunded and in respiratory distress upon his arrival. He stated he was told that an NGT was placed, followed by a bedside x-ray that showed the tube was in the patient's lung. MD #4 reported he was told the NGT was pulled out and the patient was having respiratory distress. He reported he ordered a stat chest x-ray which showed the patient had a pneumothorax. MD #4 stated he should have been notified of the placement of the NGT in the patient's lung. The physician stated that if he was notified of the incorrect placement, he would have been at the bedside when the NGT was removed due to the complication of a pneumothorax when the tube was removed.

Interview with RN #1 was requested on 02/22/2022. Interview was not obtained due to RN #1 was no longer employed at the facility.

Review of personnel file of RN #1 revealed a hire date of 06/10/2019 as a Nurse Extern with a new title of Nursing Assistant II on 07/19/2020. Review revealed a change of title for RN #1 of Staff Nurse on 09/13/2020. Review revealed no evidence of competencies or validation for skills with the Dobhoff small bore feeding tube insertion or removal. Review revealed RN #1 resigned on 12/18/2021.

Interview on 02/24/2022 at 1410 with CNO #6 revealed RN #1 had not demonstrated competencies to insert and remove Dobhoff nasogastric small bore feeding tubes. Interview revealed RN #1 was not certified to insert and remove Dobhoff tubes. Interview revealed there was no order for the insertion of a Dobhoff nasogastric small bore feeding tube. Interview revealed there was no documented notification to the physician that the Dobhoff nasogastric feeding tube was incorrectly located in the patient's lung. Interview revealed the hospital's policy for insertion and removal of the Dobhoff nasogastric feeding tube was not followed.



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2. Open medical record review of Patient #20 revealed a 73-year-old male who was admitted on 02/01/2022 with a chief complaint of Shortness of Breath. Review of the History and Physical dated 02/01/2022 at 1343 revealed, "...presents with increasing shortness of breath and chest pain... Active Hospital Problems - Hypoxia (low oxygen levels), Acute Kidney Injury superimposed on Chronic Kidney Disease, Hypertension, Diabetes Mellitus (condition causing high blood sugar levels), Chronic Obstructive Pulmonary Disease (COPD)..." Medical record review revealed "Nasogastric 16 Fr (French)" tube was inserted to a depth of 70 cm in the right nostril of Patient #20 on 02/18/2022 at 0752 by RN #10. Review of XR (X-Ray) Abdomen 1 View collected 02/18/2022 at 0833, revealed, "INDICATION: NG tube placement... IMPRESSION: Nasogastric tube projects to the distal stomach level..." Review of Nursing Assessments dated 02/24/2022 at 0800 revealed, "NG: Placement Verification: Auscultation, Tube Depth (cm): 70..." Review of Physician Orders failed to reveal an order for the insertion of a Nasogastric tube.

Review of "Competency: Small Bore Feeding Tube Insertion Competency", (no date), revealed, "PROCEDURE: Verify LIP (Licensed Independent Practitioner) order..."

Review of RN #10's "Competency: Small Bore Feeding Tube Insertion Competency" revealed the confirmation of Knowledge was signed on 08/17/2021.

Interview on 02/24/2022 at 1242 with RN #10 revealed she was a travel nurse and did not recall Patient #20. Interview revealed "there should have been an order." Interview revealed RN #10 was aware that a physician order was required to insert an NG tube. Interview revealed the insertion was not something RN #10 would initiate on her own. Interview revealed RN #10 was unsure what provider asked her to insert the NG tube.

NC00184478; NC00185973; NC00181373; NC00180156; NC0014220; NC00181842; NC00186021; NC00185995; NC00186072