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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, Nursing Services, was out of compliance.

A-0395- A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure nursing care was provided and met the continuous care needs of the patient. Specifically, the facility failed to ensure nursing services were provided according to physician orders, facility policies, and nationally recognized standards in three of three patient records reviewed with gastrostomy tubes (G-tube, a gastrostomy tube, often called a G-tube, is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine). (Patients #1, #2, and #4)

A-0398-All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). Based on document review and interviews, the facility failed to ensure nursing staff was evaluated and competent to provide care to patients with gastrostomy tubes (G-tubes) in three of three patient records reviewed with G-tubes. (Patients #1, #2, and #4) (Cross-reference A-0395)

Based on document review and interviews, the facility failed to ensure nursing care was provided and met the continuous care needs of the patient. Specifically, the facility failed to ensure nursing services were provided according to physician orders, facility policies, and nationally recognized standards in three of three medical records reviewed of patients with gastrostomy tubes (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine). (Patients #1, #2, and #4)

Findings include:

Facility policies:

The Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy read, when staff performs their initial physical assessment or reassessment if they determine that the results of those assessments are within defined limits, staff will document "WDL", within defined limits, unless unusual or unexpected findings are identified or when parameters are outside of normal. If the assessment is unusual or outside of defined limits, staff will document the information in the designated system abnormal selection. Reassessment of the hospitalized patient is a continuous, ongoing process based upon department-specific assessment parameters as well as in response to changes in diagnosis, treatments, procedures, and the plan of care. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes as determined by the caregiver. Notes should be used to document any actions/observations that do not have an appropriate or corresponding documentation section. Avoid using stated, estimated, or historical weights. A scaled weight should be obtained. Documentation of patient care is based on patient assessment and individual patient care needs.

The Clinical Skills Procedures policy read clinical staff will reference the Elsevier Clinical Skills web-based application for all clinical protocols and procedures. Elsevier Clinical Skills is the primary reference for clinical procedures. Procedures that are found in Elsevier Clinical Skills will not be included as a separate document in the Policy and Procedure Manager system. If a clinical procedure is not included in Elsevier Clinical Skills, staff will then reference and follow the facility-specific policy.

The Enteral Nutrition policy read, the scope of the policy applies to clinical patient care at facilities and excludes neonates. The purpose of the policy is to provide a safe and therapeutically effective mechanism for administering enteral nutrition (EN). Nursing administers the enteral feeding per Elsevier Clinical Key or as otherwise stated in the enteral nutrition order with an active link to Elsevier reference Feeding Tube Enteral Nutrition via nasogastric, Gastrostomy, or Jejunostomy Tube.

The Elsevier Skills Feeding Tube Enteral Nutrition policy provided by the facility read, each organization should establish practices regarding the type of water to use based on the status of the drinking water supply. Perform an abdominal assessment that includes bowel sounds, distention, discomfort, and signs of feeding intolerance. The absence of bowel sounds is not a contraindication to feeding, but report this finding and other changes from baseline assessment findings to the practitioner to determine if feedings can proceed safely. Assess the patient every 24 hours for signs of feeding tolerance (e.g., presence of flatus and stool, absence of abdominal distention or pain). Check the gastric residual volume (GRV) if the patient's condition changes and feeding intolerance is suspected. Return aspirated gastric contents to the stomach unless volume exceeds 500 ml or an amount determined by the organization's practice or practitioner's order. A GRV of greater than 500 ml may increase the risk of aspiration. Weigh the patient daily until caloric intake goals are met and tolerance is established. Then weigh the patients less frequently per the organization's practice. Verify the placement of the enteral feeding tube every four hours, using observation of tube length, observation of gastric aspirate, pH testing of gastric aspirate, or capnography per the organization's practice. Documentation should include the amount (type, frequency, volume) and rate of feeding, water flush (type, volume, and frequency), method of verification of feeding tube placement, patient's response to tube feeding, abdominal assessment findings, patency of the tube, unexpected outcomes, related interventions, and education.

References:

The Elsevier The Skills: Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Tube, provided by the facility, read, and perform an abdominal assessment that includes bowel sounds, distention, discomfort, and signs of feeding intolerance. The absence of bowel sounds is not a contraindication to feeding, but report this finding and other changes from baseline assessment findings to the practitioner to determine if feeding can proceed safely. Document the procedure in the patient's record. Flush the feeding tube with a minimum of 30 milliliters (ml) of water before and after intermittent feedings and every 4 hours during continuous feedings. Use the appropriate type of water based on the organization's practice. Auscultate bowel sounds and monitor them for trends and changes.

The Elsevier Feeding Tubes-G-Tubes policy, provided by the facility, read, assess for feeding tube migration. Review the patient's record for information regarding the numeric marking at the exit site when the tube is inserted or the external length of the tube. Observe the numeric markings on the tube at the exit site or measure the external length of the tube. Compare the lengths to see if the tube has migrated inward or outwards. Notify the practitioner if a discrepancy exists. Flush the feeding tube with a minimum of 30 ml of water before and after intermittent feedings and every four hours during continuous feedings. Use the appropriate type of water based on the organization's practice. Purified water should be used for flushing feeding tubes and hydrating immunocompromised or critically ill patients. Document the procedure in the patient's record.

Documentation should include education, condition of stoma, treatment related to site complications, tube patency, type of tube, length of external tube or numeric marking at the exit site, unexpected outcomes and related interventions, pain assessment, and management.

The Level One Practice Update sent to staff on 7/13/23 read, the Elsevier Skill Feeding Tube: Enteral Nutrition via Nasogastric, Gastrostomy, or Jejunostomy Tube Continuing Education was updated with a note based on recommendations by the American Society for Parenteral and Enteral Nutrition. The update read to mark the feeding tube upon insertion and document placement in the Epic LDA screen to assess if the tube migrates (versus checking residuals and/or aspirate).

1. The facility failed to ensure patients admitted with a G-tube received assessments and clinical care in accordance with facility policy and national standards.

A. Medical Record Review

i. Medical record review revealed on 7/11/23 at 8:22 p.m., Patient #1 presented to the emergency department (ED) for assessment of abdominal pain. Patient #1 was suspected to have an ileus (obstruction of the intestine) and upon further studies, he was found to have a bowel perforation (a hole in the intestine). Record review revealed Patient #1 was admitted with complications related to his G-tube. In addition, in a nutritional assessment note written on 7/14/23 at 4:46 p.m., registered dietician (Dietician) #5 identified Patient #1 as a high-risk patient who required nutrition support interventions

a. Patient #1's medical record revealed an order for daily weights was placed by Physician #4 on 7/15/23 at 9:59 a.m. Record review revealed Patient #1's weight fluctuated from 85.5 pounds to 102.7 pounds, which showed a weight change of 17.2 pounds while the patient was admitted. There was no evidence of daily weights conducted on 7/12/23, 7/13/23, 7/14/23, 7/15/23, 7/17/23, 7/18/23, 7/25/23, 7/26/23, 7/28/23, and 7/29/23.

This was in contrast to Elsevier Skills Feeding Tube Enteral Nutrition policy which read to weigh the patient daily until caloric intake goals were met and tolerance was established.

b. Patient #1's medical record revealed an order to assess every four hours for gastric residuals (the amount of liquid remaining in the stomach following administration of enteral feed) by Physician #4 on 7/24/23 at 12:55 p.m. Record review revealed no evidence of residuals assessed on 7/26/23, 7/27/23, 7/28/23, 7/29/23, 7/30/23, and 7/31/23.

c. Patient #1's medical record revealed an order placed on 7/21/23 at 8:04 a.m. by Physician #10 to flush the G-tube with 100 milliliters (ml) of water every four hours. Further record review revealed the only evidence of the G-tube being flushed with water was on 7/26/23.

d. Patient #1's medical record revealed bowel sound assessments for the day shift (7:00 a.m. to 7:00 p.m.) were not documented on 7/24/23 and 7/29/23. In addition, bowel sound assessments for the night shift (7:00 p.m. to 7:00 a.m.) were not documented on 7/26/23.

This was in contrast with the Skills: Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Tube, which instructed to perform an abdominal assessment that included bowel sounds, distention, discomfort, and signs of feeding intolerance. The document also instructed to auscultate the bowel sounds and monitor them for trends and changes.

ii. Medical record review revealed on 7/21/23 at 5:40 p.m., Patient #2 was brought in by ambulance to the emergency department (ED) with a dislodged G-tube. She was admitted and had surgery to place a new percutaneous endoscopic gastronomy tube (PEG tube, or feeding tube) on 7/22/23. Surgical services documented the tube to be at the 4.0 centimeter (cm) mark with excellent placement.

a. Patient #2's medical record revealed an order on 7/23/23 at 8:32 a.m. by Physician #12 for routine sterile water flushes every four hours. In addition, on 7/23/23 at 1:54 p.m. an order by a registered dietician (RD) #11 read to provide free water flushes (FWF) of 250 mls every six hours. Review of the medical record revealed no evidence of G-tube flushes provided for Patient #2. In addition, there was no evidence of tube feeding documentation noted in the medical record.

b. Patient #2's medical record revealed no evidence of checking the G-tube placement mark once the patient was out of surgery.

This was in contrast to the Elsevier Feeding Tubes-G-Tubes policy which read, documentation should include tube patency, type of tube, length of external tube, or numeric marking at the exit site.

iii. According to the medical record review, on 9/1/23 at 1:29 a.m., Patient #1 presented to the ED via ambulance in respiratory distress. ED workup showed sepsis (full body infection response) related to pneumonia (lung inflammation). Patient #4 was admitted to the intensive care unit (ICU) for care. Review of the history and physical note showed the patient had an established g-tube in place upon arrival to the ED and throughout his admission.

a. Patient #4's medical record review revealed on 9/1/23 at 2:06 p.m. an order was placed by RD #11 for 30 ml flushes of water every four hours. Record review also revealed there was no volume of flushes provided on 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/7/23.

This was in contrast to the Elsevier Feeding Tubes-G-Tubes policy which read, documentation should include the amount (type, frequency, volume) and rate of feeding, and water flush (type, volume, and frequency).

B. Interviews

i. On 9/12/23 at 11:51 a.m., an interview with RN #1 was conducted. RN #1 stated when caring for patients with g-tubes, it was important to follow orders and policies. RN #1 explained prior to starting tube feeds through a g-tube, she would check for residuals and resistance, signs and symptoms of infection, bloating, pain, nausea, and vomiting as part of her g-tube assessment. RN #1 stated the risks of not assessing for g-tube placement would include the patient not receiving medications and a risk of infection. RN#1 stated she would document her findings in the medical record.

ii. On 9/12/23 at 1:17 p.m., an interview with RN #9 was conducted. RN #9 stated she would review and follow orders written for G-tube patients. She explained that her assessment of the G-tube patient would include looking at the site for the placement of the tube, and ensuring the tube was not coming out or infusing into the wrong place. RN #9 explained the risks of flushes or medications not going to the right place as a sign of an obstruction or perforation (hole). When checking residuals RN #9 stated that she would look for excessive fluid which would concern her that the fluid wasn't being absorbed. RN #9 explained she would look for a firm distended abdomen, abdominal pain, nausea, and vomiting as signs something was backing up and would report findings to the provider.

iii. On 9/13/23 at 1:35 p.m., an interview with RN #13 was conducted. RN #13 stated she was expected to assess the G-tube site every four hours when checking vital signs. She explained her documentation would include tube and dressing appearance, drainage, medications administered with flushes, and feeding orders. RN #13 stated if there were orders for flushes or residuals she was expected to be charting amounts in the record under intake and output.

iv. On 9/13/23 at 11:11 a.m., an interview with nurse manager (Manager) #8 was conducted. Manager #8 stated staff were expected to follow physician orders and document care provided that prompted them in the medical record. Manager #8 stated that staff were provided access to the Elsevier platform which allowed them to search topics they were not familiar with. She explained that she did not conduct random medical record reviews unless there was an incident report made. She further stated she did not know if anyone at the facility conducted medical record reviews routinely to assess for compliance with following orders and facility policies.

Based on document review and interviews, the facility failed to ensure nursing staff was evaluated and competent to provide care to patients with gastrostomy tubes (G-tubes, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) in three of three medical records reviewed of patients with G-tubes. (Patients #1, #2, and #4) (Cross-reference A-0395)

Findings include:

Facility policies:

The Clinical Skills Procedures Policy read, clinical staff will reference the Elsevier Clinical Skills web-based application for all clinical protocols and procedures. Elsevier Clinical Skills is the primary reference for clinical procedures. Procedures that are found in Elsevier Clinical Skills will not be included as a separate document in the Policy and Procedure Manager (PPM) system. If a clinical procedure is not included in Elsevier Clinical Skills, staff will then reference and follow the facility-specific policy.

The Enteral Nutrition policy read, nursing administers the enteral feeding per Elsevier Clinical Key or as otherwise stated in the enteral nutrition order. Active link to: Feeding Tube: Enteral Nutrition via nasogastric, Gastrostomy, or Jejunostomy Tube.

References:

Elsevier The Skills: Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Tube, provided by the facility read, verify the placement of the enteral feeding tube every four hours, using observation of tube length, observation of gastric aspirate (a technique used to collect stomach contents), pH testing of gastric aspirate, or capnography (the monitoring of carbon dioxide in respiratory gases) per the organizations practice.

Elsevier Feeding Tubes: PEG, Gastrostomy, and Jejunostomy Care provided by the facility read, flush the feeding tube with a minimum of 30 ml of water before and after intermittent feedings and every four hours during continuous feedings. Use the appropriate type of water based on the organization's practice. Each organization should establish practices regarding the type of water to use based on the status of their drinking water supply. Follow the organization's practice or manufacturer protocols for replacement. Inflate and deflate a feeding tube with an internal balloon per the organization's practice or the manufacturer's recommendations.

The Level One Practice Update sent to staff on 7/13/23 read, A note was added to Elsevier Skill: Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Tube based on recommendations by the American Society for Parenteral and Enteral Nutrition. Mark the feeding tube upon insertion and document placement in the medical record screen to assess if the tube migrates (vs. checking residuals and/or aspirate). Only check residuals if the registered nurse (RN) suspects the tube is not in the correct place/position.

1. The facility failed to ensure staff received guidance and training on how to care for patients with G-tubes.

A. Document Review

i. Review of policies provided by the facility titled The Clinical Skills Procedures Policy and The Enteral Nutrition policy revealed referral the policies instructed to refer to the Elsevier site for guidance. Review of Elsevier The Skills: Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Tube, and Elsevier Feeding Tubes: PEG, Gastrostomy, and Jejunostomy Care revealed referrals to follow the organization's practice. This resulted in a lack of guidance provided for staff who were searching for instruction on how to care for patients with G-tubes.

ii. The Level One Practice Update sent to staff on 7/13/23 read, a note was added to the Elsevier Skill: Feeding Tube: Enteral Nutrition via Nasoenteric, Gastrostomy, or Jejunostomy Tube document to mark the feeding tube upon insertion and document placement in the medical record to assess if the tube migrated (vs. checking residuals and/or aspirate). The note further instructed to only check residuals if the RN suspected the tube was not in the correct place/position.

This note was not updated to the policy Elsevier Feeding Tubes: PEG, Gastrostomy, and Jejunostomy Care, which read, verify the placement of the enteral feeding tube every four hours, using observation of tube length, observation of gastric aspirate, pH testing of gastric aspirate, or capnography per the organization's practice.

The lack of providing the note to both policies regarding the care of patients with feeding tubes created an inconsistent conflict of information surrounding the expectations of residuals and tube placement checks in G-tube patients.

iii. On 9/13/23 at 1:47 p.m. review of an email from the regulatory affairs program manager (RN) #14 revealed there was no G-tube orientation provided for nurses. Further review of the email revealed nurses were instructed to reference Elsevier and were allowed to ask questions during orientation.

B. Medical Record Review

i. Medical record review of Patients #1, #2, and #4 revealed each patient had a G-tube present during their visits. Further medical record review revealed gaps in care, including missing water flushes, daily weights, bowel sound assessments, and checking tube placement in accordance with physician orders, facility policies, and national standards. (Cross-reference A-0395)

C. Interviews

i. On 9/19/23 at 12:23 p.m., an interview with RN #1 was conducted. RN#1 stated when starting tube feeds on G-tube patients she would check residual and resistance. She stated she did not recall receiving training for G-tubes when she started at the facility and reported she would review the Elsevier policy or consult with her charge nurse or manager before treating a patient with a G-tube if she had concerns about providing the care.

RN #1's interview was in contrast to the Level One Practice Update sent to staff on 7/13/23, which advised against checking for residuals unless the RN suspected the tube was not in the correct position.

ii. On 9/13/23 at 1:35 p.m., an interview with RN #13 was conducted. RN #13 stated the facility used Elsevier for guidance so she would start there with any questions about patient care and if instructed to reference a facility policy, she would ask her charge nurse or educator because she was not sure where the policies were located.

iii. On 9/13/23 at 11:11 a.m., an interview with the nurse manager of the medical surgical unit (Manager) #8 was conducted. She explained her role was to support the educator and ensure her staff completed their assigned modules given to them by the educator. RN #8 stated she did no know how staff were trained on G-tubes and she would have to refer to the educator. She stated she felt comfortable that seasoned nurses would ask her or the charge nurse if they needed training. She reported the unit cared for G-tube patients periodically and she would not know when a G-tube patient was on the unit unless there was a concern about the patient reported to her.

iv. On 9/12/23 at 4:27 p.m., an interview with Educator #6 was held. Educator #6 stated that she had not personally integrated G-tube training into her curriculum for the facility, and there would not be a preceptor checklist item for G-tube care. Educator #6 explained that checklists were more established for higher-level care items, such as chest tubes. She explained if nurses were not confident about how to perform certain tasks, they were expected to refer to the Elsevier platform that provided policies and procedures for the facility.

v. On 9/13/23 at 8:47 a.m., an interview with the vice president for nursing (VP) #7 was conducted. VP #7 explained she oversaw the educators for the region and her role included deciding what policies and procedures were included for nursing practice. She stated that she ensured resources were available to educators which allowed them to make decisions on what education was provided to staff.