HospitalInspections.org

A0385
This CONDITION is not met as evidenced by:

Based on policy review, medical record review, document review, and interview, it was determined that nursing services did not provide supervised care as evidenced by: Nursing staff did not performed assessments and/or check the feed tube placement every four hours for Patient #2, who was receiving continuous enteral tube feedings (Tag-A0395). Nursing staff did not clarify the continuous enteral tube feed order with the provider for Patient #2 (Tag-A0405). Nursing staff did not report the aspiration event/incorrect enteral tube feed order to the facility incident reporting system (Tag-A0411). This failure resulted in an aspiration event for Patient #2.

Cross Reference:
482.23(b)(3)- Nursing Services: RN Supervision of Nursing Care
482.23(c)(1), (c)(i) & (c)(2)- Nursing Services: Administration of Drugs
482.23(c)(5)- Nursing Services: Reporting Adverse Reactions and Errors

Based on policy review, medical record review, and interview, nursing staff did not performed assessments and/or check the feed tube placement every four hours for Patient #2, who was receiving continuous enteral tube feedings. Lack of patient assessment places a patient at a greater risk of aspirating.

Findings include:

Review on 11/02/23 of policies "Enteral Tube Feeding, Gastric," "Enteral Tube Feeding, Continuous Gastrostomy and Jejunostomy," and "Enteral Tube Feeding, Intermittent, Gastrostomy and Jejunostomy," all revised 11/2022 revealed nursing staff are to assess for gastrointestinal intolerance every four hours by assessing abdominal distention. Documentation for enteral tube feedings includes, but not limited to, date/time/amount of each enteral tube feeding, type of formula, infusion method and rate, patient tolerance to procedure and formula, gastric residual volume, gastrointestinal assessment, and enteral tube feeding problems or complications.

Review of policy "Impaired Swallowing and Aspiration Precautions," last revised 02/2023 revealed patients that have impaired swallowing are at high risk for aspiration. For patients with a continuous feeding, assess feeding tube placement before feeding and every four hours by either observing for a change in external feeding tube length and aspirating gastric contents from the feeding tube and observing for changes in volume/appearance/color of aspirate. Assess the patient for gastrointestinal intolerance of enteral tube feedings every four hours by assessing for abdominal distention, monitoring for abdominal pain, and observe for passage of flatus (passing gas) and stool.

Review on 11/03/23 of medical record for Patient #2 revealed on 08/11/23 at 09:00 AM, nursing staff documented that feeding tube placement was checked via aspiration. Patient #2's lung sounds were diminished. At 10:46 AM, the physician documented that Patient #2's lung sounds were clear. At 10:48 AM, Staff (T), Physician ordered "Glucerna 1.5 tube feed, continuous, start rate 215 ml per hour, increase by 0, goal rate 5x daily, delegate tube feed modifications and modular orders to the dietician, 60 ml free water flush after each feed" and to check for residuals (hold if greater than 500 mls). At 07:45 PM, nursing staff documented that Patient #2 had coarse/rhonchi (a breath sound characterized by a low-pitch sound during breathing that occurs when fluid or mucus accumulates in the respiratory system) in the right lower lung lobe. At 10:00 PM, the nursing documented that Patient #2 had audible respirations, an elevated heart rate, and a decreased oxygen saturation. The residual check was over 600 mls. At 10:30 PM, nursing documented that Patient #2 aspirated the tube feed, and a "Condition C" (rapid response) was called.
No evidence was found in the medical record to indicate nursing staff performed GI assessments and check the feed tube placement per policy every four hours following the 09:00 AM assessment until 07:45 PM.

Interview on 11/02/23 at 11:00 AM with Staff (B), RN & Vice President of Patient Care/Chief Nursing Officer, and Staff (C), RN Clinical Director Nursing/Quality, confirmed these findings.

Based on policy review, medical record review, and interview, the physician ordered an enteral tube feeding administration rate as continuous instead of by bolus. The nursing staff did not clarify the enteral tube feed order with the provider for Patient #2. Patient #2 experienced an acute hypoxemic respiratory failure event, secondary to the aspiration of tube feed contents.

Findings include:

Review of policy "Enteral Tube Feeding, Gastric," and "Enteral Tube Feeding, Continuous Gastrostomy and Jejunostomy," both revised 11/2022 revealed that when implementing a tube feed, staff are to verify the practitioner's order, the enteral feeding device, the prescribed formula, the administration method, the volume, and the rate, type, volume, and frequency of the water flushes.

Review on 11/03/23 of medical record for Patient #2 revealed on 08/11/23 at 10:48 AM, Staff (T), Physician ordered "Glucerna 1.5 tube feed, Continuous, start rate 215 ml per hour, increase by 0, goal rate 5x daily, delegate tube feed modifications and modular orders to the dietician, 60 ml free water flush after each feed and to check for residuals (hold greater than 500 ml). At 11:48 AM, Staff (W), Registered Nurse, reviewed and validated the tube feed order by Staff (T), Physician in the electronic medical record. At 10:30 PM, nursing documented that Patient #2 aspirated the tube feed, and a "Condition C" (rapid response) was called. On 08/12/23 at 07:58 AM, Staff (T), Physician documented that on the night of 08/11/23, Patient #2 had an aspiration event and it appeared that Patient #2 was receiving continuous feeds rather than bolus feeds based on the order review.

Interviews on 11/01/23 at 12:30 PM with Staff (L), Registered Nurse and at 12:40 PM with Staff (Q), Registered Nurse, both from floor 5D revealed that if the tube feed order was unclear, the prescribing provider would be contacted to clarify the order.

Telephone interview on 11/27/23 at 09:50 AM with Staff (T), Physician revealed Staff (T) was aware Patient #2 was on home bolus feedings of Glucerna 1.5 five times a day. On 08/11/23, Staff (T) put the order in the electronic medical record for Patient #2's home feed of Glucerna 1.5, bolus feeding of 215 ml followed by 60 ml water flush five times a day. On 08/12/23, Staff (T) learned Patient #2 had a hypoxic event on 08/11/23. Upon review of the event and the order, Staff (T) discovered that the order had defaulted to "continuous" and not "bolus" as Staff (T) stated was originally selected. A normal rate of 1.5 calorie formula for an average sized adult would be 40 ml to 55 ml per hour (40-55 ml/hr.). Staff (T) stated that 215 ml/hr. as a continuous feed is not a normal order and is too much volume. Patient #2's feed was running continuously at 215 ml/hr.

Telephone interview on 11/27/23 at 10:15 AM with Staff (II), Registered Dietician, revealed on 08/10/23, Staff (II) evaluated Patient #2 and recommended Glucerna 1.5 at 25ml/hr. with 10 ml increases every 6 hours to a goal rate of 45 ml/hr. A rate of 45 ml/hr. is a normal rate for a patient the size of Patient #2. (The enteral tube feeding was running at 215 ml/hr.). A continuous tube feed rate of 45 ml/hr. is a normal rate for a patient the size of Patient #2. Staff (II) stated that if bolus tube feeds were desired, Glucerna 1.5, 225 ml, five times a day would be appropriate.

Interview on 11/02/23 at 11:00 AM with Staff (B), RN & Vice President of Patient Care/Chief Nursing Officer, and Staff (C), RN Clinical Director Nursing/Quality, confirmed these findings.

Based on policy review, medical record, interview, and document review, staff did not report Patient #2's aspiration event/incorrect enteral tube feed order that occurred on 08/11/23 to the facility incident reporting system. Failure to report adverse events has the potential for not identifying issues and implementing actions to improve the quality of patient care.

Findings include:

Review of policy "Initial Incident/Event Reporting", last revised December 2022, revealed a "Reportable Event" is any incident, medication event, sentinel event, serious event, or infrastructure failure. A "Sentinel Event" is any unanticipated event in the healthcare setting resulting in death or serious physical injury to a patient not related to natural course of the patient's illness. A "Serious Event" is an event, occurrence, or situation involving the clinical care of a patient that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient. An individual with knowledge of a reportable patient event shall report the event immediately or as soon as possible, but no later than 24 hours after occurrence of discovery via the Initial Incident/Event Report reporting process and shall provide as much information as reasonably possible.

Review of policy "Reporting Serious Adverse Events", last revised July 2020 revealed a sentinel event is patient safety event (not primarily related to the natural course of the patient illness or underlaying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm. The staff member will notify supervision at once. The supervisor will contact the Quality Department. A patient incident report and Patient Incident Review Form must be completed.

Review on 11/03/23 of medical record for Patient #2 revealed on 08/11/23, a "Condition C" (rapid response) was called for Patient #2 after becoming hypoxic with high systolic blood pressure, a high pulse rate, and appearing to be in respiratory arrest. Oral suctioning and gastric contents showed tube feed solution. The tube feed was stopped, and Patient #2 was transferred to the intensive care unit (ICU). On 08/12/23, in the ICU, Patient #2 developed hypoxia again and there was a concern of recurring aspiration. At 07:58 AM, Staff (T), documented that on the night of 08/11/23, "Patient #2 had an aspiration event .... and that it appears that Patient #2 was receiving continuous feeds rather than bolus feed based on the order review."

Interview on 11/01/23 at 02:00 PM Staff (B), RN and Vice President of Patient Care/Chief Nursing Officer, and Staff (C), RN Clinical Director Nursing/Quality, revealed there were no complaints, grievances, adverse events, and/or provider reviews related to Patient #2.

Review on 11/02/23 of the Adverse Events Log from 05/2023 and Complaints/Grievances Log from 05/2023 to present revealed no evidence of an event report, complaint, or grievance related to the aspiration events that occurred on 08/11/23 and 08/12/23 for Patient #2.