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Based on review of Governing Body Bylaws, medical records, policy and procedures and staff interviews it was determined that the facility's Governing Body failed to ensure that physician orders were followed as ordered when one patient (P) (P#4) of four patients (P#1, P#2, P#3, and P#4) was reviewed. Specifically, the physician ordered P#4's nasogastric (NG) tube to be set on low intermittent suction (used for removing gastric secretions from the stomach) and suction setting was found to be on continuous that resulted in nausea, vomiting, and blood loss for P#4.

Findings included:

A review of the facility 'Bylaws', effective 8/28/2019 revealed that in Article IV, section 4.7 titled 'Responsibilities' that the purpose of the Board was to govern the operation of the System and other facilities leased, constructed, operated or acquired by the Corporation. The responsibilities of the Board are to:
(d) Evaluate all phases of System performance, including the quality of medical care and fiscal management.

Cross-refer to A-0385 as it relates to the facility's failure to provide patient care as ordered for P#4.

Based on the review of medical records, the facility's policies/procedures, and staff interviews, the facility failed to follow physician orders for one patient (P) (P#4) of four patients (P#1, P#2, P#3, and P#4) reviewed. Specifically, the physician ordered P#4's Nasogastric (NG) tube to be set on low intermittent suction (used for removing gastric secretions from the stomach) and suction setting was found to be on continuous that resulted in nausea, vomiting, and blood loss for P#4.


Findings include:

Cross- refer to A0392 as it relates to the facility's failure to provide patient care as ordered to one patient (P#4) of four patients (P#1, P#2, P#3, and P#4) reviewed.

Based on the review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to follow physician orders of one patient (P#4) of four patients (P#1, P#2, P#3, and P#4) reviewed when it was determined that the Nasogastric (NG) tube (a thin, soft tube made of plastic or rubber that is passed through the nose, down through the throat, and into the stomach to deliver food, liquids, or medication) was on maximum continuous suctioning instead of low intermittent suctioning as ordered.


Findings include:


A review of the medical record revealed that P#4 was admitted to the facility on 8/29/24 at 7:52 a.m. with the diagnosis of abdominal pain secondary to a tubo-ovarian abscess (one of the late complications of pelvic inflammatory disease and can be life-threatening) and acute gastrointestinal (GI) bleeding (bleeding inside the intestinal tract).


A review of the history and physical (H&P) dated 8/29/24 at 8:29 a.m. revealed that P#4 presented to the emergency room (ER) on 8/27/24 with findings consistent with enterocolitis (inflammation of the digestive tract), infection, or inflammation. P#4 was discharged home with loperamide (medication that can treat diarrhea), Zofran (medication that can prevent nausea and vomiting), and Levsin (medication to treat muscle cramps in the bowels or bladder). Continued review revealed that P#4 returned to the emergency room when symptoms persisted. Repeat diagnostic examination revealed an acute small bowel obstruction with a transition point in the upper pelvis (a medical condition where the small intestine is blocked).


An order for Nasogastric (NG) Tube was entered by Emergency Department Physician (EDP) JJ on 8/29/24 at 5:09 a.m. The NG tube was placed by Registered Nurse (RN) GG on 8/29/24 at 6:10 a.m. in the Emergency Room (ER).

A continued review of the medical record revealed that an X-ray (test using radiation to take pictures of the inside of the body) to confirm the placement of the NG tube was done on 8/29/24 at 7:30 a.m. Continued review revealed that RN EE contacted the physician on-call on 8/29/24 at 6:47 p.m. to confirm the NG tube needed to be on intermittent or continuous suctioning.


Physician Assistant (PA) FF modified the NG tube order to include " Low intermittent Suction " on 8/29/24 at 7:15 p.m. Medical Doctor (MD) BB countersigned the order.


A review of the gastroenterology consultation notes dated 9/2/24 at 5:10 p.m. revealed that P#4's NG tube had been left on continuous suction, and P#4 had developed nausea, vomiting, and melena (black stools). Documentation also revealed that P#4 's hemoglobin (a protein containing iron that facilitates the transportation of oxygen in red blood cells-for women healthy range 11.6 to 15 grams per deciliter) decreased from 9.3 the day prior to 7.6 that day. The plan was to repeat the hemoglobin level and continue NG suction at low intermittent suction.


A review of the physician 's progress notes titled 'Assessment/Plan' on 9/5/24 at 6:19 p.m. revealed that the NG suction had been set to continuous at the maximum level for multiple hours prior to the morning on 9/2/24.


On the morning of 9/2/2024, P#4 developed hematemesis (vomiting blood) and melena, and her hemoglobin decreased from 9.3 to 5.8. P#4 was transfused with two units of blood and the hemoglobin increased to 9.5.


P#4 was discharged home on 9/10/24 at 7:45 p.m. with home health services. The discharge diagnoses included tubo-ovarian abscess, small bowel obstruction, gastric ulcer secondary to nasogastric (NG) tube trauma, and acute blood loss anemia.


A review of the facility's policy #11779 titled "Patient Assessment and Reassessment," last revised 10/21/24, revealed that it was the policy of the facility to provide a standard approach throughout the organization (including inpatient and outpatient services) for patient assessment. The assessment included an evaluation of the patient ' s relevant physical, psychological, and social status.
Reassessment:
1. Each patient was reassessed at regularly specified times related to the patient's course of treatment. The objective of the reassessment was to ensure that the patient's status is periodically reviewed so care decisions remain appropriate.
2. A reassessment will occur when there is a significant change in the patient's condition or when a significant change occurs in the patient's diagnosis.
3. Reassessment will be documented in the medical record.
4. The time of assessment will be reflected in the medical record.
5. If the patient's direct caregiver is an LPN, the RN with assigned oversight will review the shift assessment and reassessment.


A review of the facility 's policy #29522 titled "Nasogastric (NG), Orogastric (OG), Enteric Feeding Tube," last revised 1/15/24 revealed the following:
Nurses may insert and remove large-bore nasogastric, and orogastric tubes for gastric decompression with a physician order.
a. Nurses would make a reasonable effort to insert the nasogastric tube, with a recommended maximum of two attempts. The total limit of attempts at insertion to four.
Nurses may remove enteric feeding tubes or large bore nasogastric tubes as directed by physician order.
Placement of NG, OG, or enteric tubes in esophageal or bariatric surgery patients will follow the hospital policy of obtaining an order for and ensuring confirmation by X-ray.
NG, OG, or enteric tubes may be removed from esophageal or gastric surgery patients by a nurse with a physician's order. Large bore NG tube or Orogastric tube insertion:
Nurses will verify an order has been placed for a confirmation x-ray of placement following tube insertion. This pertains to insertion with or without the placement device. A nasogastric tube or orogastric tube for decompression may be immediately connected to suction prior to the x-ray confirmation of placement. No medications, flushes, or feedings may be administered through the tube without X-ray confirmation.
Nurses will refer to the physician's order for instructions related to the use of the tube following insertion (i.e. suction, gravity, clamp, etc.) after confirmation of placement is obtained.


An interview took place in the facility 's conference room on 12/3/24 at 9:00 a.m. with the Nursing Emergency Department Director (NED) AA who stated that the order for a Nasogastric (NG) tube for P#4 was entered on 8/29/24 at 5:00 a.m. and the NG tube was inserted on 8/29/24 at 6:10 a.m. in the Emergency room (ER) before P#4 was transferred to the floor.


During a telephone interview on 12/3/24 at 9:55 a.m. with Medical Doctor (MD) BB, stated that in most cases, routine management for an NG tube would be put on intermittent suction. MD BB stated that he was probably on call the day P#4 was admitted to the facility as he (MD BB) cosigned the NG tube order. PA FF modified for P#4.


An interview took place in the facility 's conference room on 12/3/24 at 10:15 a.m. with Chief Nursing Officer (CNO) CC who stated that she was not aware of P#4 's incident. CNO CC stated that generally, hand-off was usually done at the bedside and that might have been when incorrect suction setting was observed. CNO CC explained that nurses receive training to ensure competency in NG tube insertion and management.


A telephone interview took place on 12/3/24 at 10:45 a.m. with Registered Nurse (RN) EE who stated that nurses were required to follow doctor 's orders, and the doctor was required to chart in an NG tube order if the suctioning was to be intermittent or continuous. RN EE stated that if there was an omission on the doctor 's part, the doctor would be contacted to clarify the order. RN EE stated that she could not recall P#4.


A telephone interview took place on 12/3/24 at 11:00 a.m. with Physician Assistant (PA) FF who stated that he only met P#4 once, and did not follow P#4's case because he (PA FF) was not assigned to round on her. PA FF stated that the NG tube was placed for decompression, and he (PA FF) modified the order placed by EDP JJ by adding that the NG tube should be on low intermittent suction. PA FF also stated that usually the only time suction was placed on continuous suction would be with a chest tube because if a continuous suction was placed on the bowel, it could possibly lead to an ulcer.


An interview took place in the facility 's conference room on 12/3/24 at 11:20 a.m. with RN GG who stated that she was the charge nurse on duty the day P#4 was admitted to the emergency room. RN GG stated that the doctor had ordered an NG tube, and she (RN GG) went to insert the NG tube, and an X-ray was done at P#4 's bedside to confirm placement. RN GG explained that it was part of the protocol to put an NG tube on low intermittent suction unless otherwise ordered by the doctor.


During an interview with Charge Nurse/Supervisor (CN) HH in the facility 's conference room on 12/3/24 at 11:40 a.m. CN HH explained that nurses round on all patients during hand-off.
CN HH recalled that the primary nurse for P#4 and a doctor informed her that P#4's NG suction was found on maximum continuous instead of low intermittent. CN HH stated that the doctor ordered labs, and (CN HH) tried to reassure P#4 and P#4's family.
CN HH recalled that shortly after, P#4's family member reported that P#4 was vomiting blood and passing bloody stools. CN HH stated that the NG suction was turned off as it was clogged with blood and the rapid response team was called. P#4 was transferred to an intermediate care unit for one-to-one observation. CN HH explained that nurses were required to monitor an NG tubes output every four hours. CN HH recalled that the oncoming nurse RN LL confirmed that the NG canister was filled with blood after hand-off around 7:30 a.m.


A telephone interview took place on 12/3/24 at 12:45 p.m. with Emergency Department (ED) Physician (EDP) JJ who recalled that she ordered an NG tube insertion for P#4 because (P#4) was in a lot of pain. She further stated that NG tubes were usually placed on low intermittent suction. EDP JJ stated that a potential complication of any NG tube was an ulcer regardless of the suction setting. EDP JJ also stated that patients were always educated on the pros and cons of having an NG tube.


During a telephone interview on 12/3/24 at 2:50 p.m. with RN LL recalled getting hand-off from RN II. She stated that the bedside hand-off was done in the hallway because P#4 had requested for the lights to be turned off because (P#4) wanted to sleep. RN LL stated that she did not turn on the light but she checked the intravenous line and the NG tube, which was flowing. RN LL recalled that later in the morning, she observed that the NG suction was on maximum continuous.
RN LL stated that the doctor walked in at the same time and educated P#4 and her family about why the canister contained a little blood. RN LL also stated that the suction was not functioning properly as the aerator was clogged with blood, which triggered P#4 to cough up blood. P#4 was transferred to the intermediate care unit for one-to-one observation.