HospitalInspections.org

Based on record review and interview, the facility failed to ensure a physician order was obtained for a nasogastric (NG) tube prior to insertion; and failed to ensure an NG tube inserted with difficulty was checked for proper placement prior to use. This affected one (Patient #4) of three patients reviewed with NG tubes.

See A144.

Based on record review and interview, the facility failed to ensure a physician order was obtained for a nasogastric (NG) tube prior to insertion; and failed to ensure an NG tube inserted with difficulty was checked for proper placement prior to use. This affected one (Patient #4) of three patients reviewed with NG tubes.

Findings include:

Patient #4 presented to the emergency department on 02/03/19 at 7:17 A.M. with viral symptoms. The patient's chief complaint was fever with coarse breath sounds, cough and fever.

A physician progress note dated 02/03/19 at 7:33 A.M. stated the patient was restless, diaphoretic, and had an uncontrollable cough.

A physician progress note dated 02/03/19 at 9:42 A.M. stated the patient was moved to the critical care side of the emergency department because his work of breathing was not helped with steroids. The note stated he was placed on BiPap and given a sedative to facilitate the application of the BiPap.

A respiratory therapy note dated 02/03/19 at 11:00 AM that stated the patient's oxygen levels began to desaturate, and the patient was suctioned for large amounts of thick, pale yellow secretions. The patient's oxygen level after suctioning was 96 percent.

The patient was admitted to the hospital on 02/03/19 at 12:46 P.M. with diagnoses of sepsis with septic shock, acute and chronic respiratory failure, acute respiratory distress, bacterial pneumonia, and acute kidney failure.

Progress notes revealed Patient #4 was intubated on 02/04/19 at 2:36 A.M. On 02/05/19 at 1:30 P.M., a nasogastric (NG) tube was placed. The medical record contained no physician order for the placement of the NG tube. The tube placement was checked by measuring the tube length only. Tube feed was started at 20 cubic centimeters (CC) per hour and ran from 3:00 P.M. to 7:00 P.M.

A nursing progress note dated 02/05/19 at 3:18 P.M. documented the patient was suctioned for scant and clear amount of sputum. At 5:40 P.M. the note stated the patient was suctioned for "copious" secretions. The note concluded with the patient being placed on a paralytic drip.

A portable chest x-ray report dated 02/06/19 at 3:39 A.M. stated an "enteric tube with side penetration, overlying the left chest with tip directed into the left lower lung. The finding was recognized at 0300 hours and 15 minutes this morning."

A physician progress note dated 02/06/19 at 10:44 A.M. stated, the patient "had inadvertent placement of NG to left bronchus and some feeds given."

During interview on 04/03/19 at 2:00 P.M., Staff J confirmed there was not a physician order for insertion of the NG tube.

On 04/03/19 at 4:00 P.M., Staff A, the Quality Director, stated the facility investigated this incident. Staff A explained Staff B, who inserted the NG tube for Patient #4, revealed during interview at the time of the investigation that another nurse and Physician B had attempted to place the NG tube prior, but was unable to do so.

During interviews on 04/04/19 between 9:45 A.M. and 10:15 A.M., Staff D, Staff E, Staff F, Staff G, Staff H and Staff I stated if the insertion of an NG tube was problematic, then an x-ray would be requested to check placement.

Review of the facility policy titled "Gastric Tube: Nasal Gastric (NG) and Oral Gastric (OG) Tube Placement, Management and Removal", dated October 2016, stated:

"1. Practitioners will order NG or OG tubes an the purpose for the tube. Additionally, the order may state: "gastric tube to be inserted by practitioner only.

2. An individual will attempt insertion no more than twice before asking another resource for help or calling the practitioner.

4. Verification of correct placement of an indwelling NG/OG tube will occur prior to administration of medications or fluids. For continuous feedings, verification will occur minimally with change of caregiver and change of clinical conditions especially respiratory status.

10. Confirm the position of the tube with one of the following or ideally with more than one method.

a. Clinical appearance/assessment- patient does not demonstrate change in baseline respiratory status after insertion of tube

b. The marking on the tube is at the nostril or comer of the mouth depending on if NG or OG

c. Aspirate stomach contents observing appearance and also check pH if able to get an aspirate

d. Consider obtaining an x-ray to confirm tip location when the NG tube placement is questioned, the ease of insertion was not as expected or the patient is high risk."