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Based on medical record review, policy review, and interview, in one of one medical records, the hospital failed to ensure that nursing staff documented two unsuccessful attempts of placement of a weighted feeding tube. Specifically, the unsuccessful placement of the weighted feeding tube caused a pneumothorax (air leak into the space between the lung and chest wall). (Patient #1)

Review on 02/21/25 of policy "Weighted Feeding Tube", dated 06/17/09, revealed insertion of the weighted feeding tube documentation should include the size of the tube, placement, insertion site, verification of placement, drainage (if any), x-ray, and the comfort level of the patient. (The policy did not address the need for documentation of a tube that was not placed in the correct position.)

Review on 02/21/25 of policy "Assessment and Documentation", dated 06/14/24, revealed patient care will be governed by the attached standards of nursing care. The nursing standards of care revealed a head-to-toe assessment is required on a change in status and intervention. (The policy did not address the need for documentation of an adverse event of an intervention.)

Review on 02/21/25 of the medical record of Patient #1 revealed no evidence of nursing documentation of two unsuccessful placements of a weighted feeding tube on 08/05/24. On 08/05/24 at 07:12 PM, Staff (N), Physician, documented a significant event that revealed a weighted feeding tube was attempted twice and unfortunately it was difficult to place the feeding tube and the x-ray showed the feeding tube tip in the right lung. The tube was pulled out and the next x-ray revealed a small to moderate pneumothorax.

Interview on 02/20/25 at 02:15 PM with Staff (O), Registered Nurse, revealed that they were the primary nurse for Patient #1 on 08/05/24. Staff (O) did not recall inserting the weighted feeding tube for Patient #1. If there was difficulty with placement of the weighted feeding tube, they likely would have asked Staff (K), Registered Nurse to assist in the procedure. If there were any complications while attempting to place the weighted feeding tube it would be documented in a free text note in the electronic medical record.

Interview on 02/20/25 at 02:25 PM with Staff (K), Registered Nurse, revealed that Staff (K) did not recall the exact events of the weighted feeding tube insertion on 08/05/24 but stated "my guess would be that Staff (O), Registered Nurse, attempted to place the weighted feeding tube and was unsuccessful." Staff (K) would have made the second attempt of insertion. Staff (K) stated "I assume that I gave the patient (Patient #1) a pneumothorax, but I don't recall actually placing the tube." The x-ray showed the weighted feeding tube was in the right lung, and it was removed. Patient #1 ended up with a small pneumothorax in the right lung. The attempted insertion of the weighted feeding tube would be charted in a free text note in the electronic medical record by the bedside nurse.

Interview on 02/20/25 at 01:30 PM with Staff (F), Quality Nurse, verified that there was no nursing documentation of the insertion of a weighted feeding tube for Patient #1 on 08/05/24.