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Based on observation, interview, record review, and policy review, the hospital failed to:
- Discard expired tube feed (TF) and change tubing for two current patients (#18 and #24);
- Follow physician orders for free water flushes for one current patient (#18);
- Ensure a physician order was present prior to nasogastric tube (NG, soft, flexible tube inserted through the nose and into the stomach to remove stomach contents, or to instill drugs, liquids, or liquid food) insertion for one current patient (#33);
- Date TF supplies for two current patients (#18 and #24);
- Document TF and free water flushes on two current patients (#24 and #33);
- Check residual aspirate for TF on three current patients (#18, #24, and #33);
- Ensure staff were not scanning patient identification bands that were not attached to the patient for two current patients (#14 and #18); and
- Ensure venous access device (VAD) dressings were labeled per policy for 16 current patients (#1, #2, #5, #6, #7, #9, #10, #12, #13, #14, #17, #20, #21, #22, #24, and #26).

These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0395.

Based on observation, interview, record review, and policy review, the hospital failed to:
- Discard expired tube feed (TF) and change tubing for two current patients (#18 and #24) of four observed;
- Follow physician orders for free water flushes for one current patient (#18) of four observed;
- Ensure a physician order was present prior to nasogastric tube (NG, soft, flexible tube inserted through the nose and into the stomach to remove stomach contents, or to instill drugs, liquids, or liquid food) insertion for one current patient (#33) of four observed;
- Date TF supplies for two current patients (#18 and #24);
- Document TF and free water flushes on two current patients (#24 and #33) of four observed;
- Check residual aspirate for TF on three current patients (#18, #24, and #33) of four observed;
- Ensure staff were not scanning patient identification bands that were not attached to the patient for two current patients (#14 and #18); and
- Ensure venous access device (VAD) dressings were labeled per policy for 16 current patients (#1, #2, #5, #6, #7, #9, #10, #12, #13, #14, #17, #20, #21, #22, #24, and #26) of 24 observed.

Findings included:

Review of the hospital's policy titled, "Enteral Nutrition Feeding," revised 02/2022, showed enteral feeding tubes must be labeled prior to infusion and staff were to:
- Assess the patient every shift and as needed.
- Change tubing and discard unused enteral feeding after 24 hours when a closed system was used.
- Change tubing and discard unused enteral feeding after eight hours when an open system was used.
- Measure and document TF residual every four hours in critical care areas and every eight hours on general medical floor units.
- Document the assessment, patient's tolerance/response to feeding, type and amount of feedings, presence or absence of complications, the character and amount of residual aspirate and whether it was returned or discarded.

Review of Patient #18's medical record, dated 07/12/25, showed a 60-year-old female with a past medical history of gastro-esophageal reflux disease (GERD, a digestive disease in which stomach acid or bile irritates the food pipe lining), depression, and insomnia (difficulty falling asleep or staying asleep) presented to the Emergency Department (ED) after suffering a cardiac arrest (when the heart suddenly and unexpectedly stops pumping). She underwent ten minutes of cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped), was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) and a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) and angioplasty (a procedure to repair or unblock a blood vessel) were performed. An orogastric tube (OG, small tubes placed through the mouth and end with the tip in the stomach) was placed for suctioning and the administration of medications and TF.
- On 07/15/25 at 4:22 PM, a physician's order showed TF with a goal of 50 milliliters (mL) per hour and a water flush of 50 mL every six hours. The TF would be managed by a dietician.
- On 07/16/25, a total of 131 mL of TF and 50 mL of water were administered. The dietician's note indicated Patient #18 was tolerating the TF at 40 mL per hour.
- On 07/17/25, a total of 403 mL of TF and 100 mL of water were administered.
- On 07/18/25, a total of 1015 mL of TF and 150 mL of water were administered. The dietician's note indicated Patient #18 was tolerating the TF at 45 mL per hour.
- On 07/19/25, a total 445 mL of TF and 100 mL of water were administered.
- On 07/20/25, a total 619 mL of TF and 100 mL of water were administered.
- On 07/21/25, a total 1413 mL of TF and 193 mL of water were administered. The dietician's note indicated Patient #18 was tolerating the TF. She was extubated (removal of breathing tube) and an NG tube was placed.
- From 07/22/25 through 07/26/25, there was no documentation of TF or water being administered.
- On 07/22/25, the dietician's note indicated the TF was off but would be resumed that day.
- On 07/23/25, the dietician's note indicated the TF was running at 25 mL per hour but would be held for a swallow study.
- On 07/24/25, the dietician's note indicated Patient #18's TF goal remained the same, at 50 mL per hour.
- On 07/25/25, the dietician's note indicated that Patient #18's husband reported the TF had been on hold since 7:00 PM the night before due to increased secretions and coughing. A gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) consult was ordered for possible percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tube placement.
- On 07/26/25, nursing documentation indicated the TF was running at 10 mL per hour.
- On 07/27/25, a total of 181 mL of TF and 100 mL of water were administered.
- On 07/28/25, a total of 111 mL of TF and 100 mL of water were administered.
- On 07/29/25, a total 150 mL of TF and no water were administered.
- On 07/30/25, Patient #18 had a PEG tube placed, and TF were scheduled to resume the following day.
- From 07/15/25 through 07/30/25, there was no documentation of residual assessments.

During concurrent observation and interview on 07/29/25 at 9:35 AM, with Staff U, Registered Nurse (RN), showed:
- Two undated, clear plastic cups and an undated, open large volume syringe were stored on paper towels at the sink and were used to administer medications through Patient #18's NG tube. Staff U stated that some staff members dated the supplies but she just changed them out every few days. She was unsure when those specific supplies were opened but "they looked clean".
- A bottle of TF, dated 07/26/25 at 6:20 PM, was administered Patient #18 through a TF pump. Staff U stated that the date on the bottle was the opened date and that it was good for 24 hours. She indicated that Patient #18 had not been able to tolerate the TF and had not been getting it at the rate ordered. It was okay to continue using the bottle, until it ran out.
- The tubing and a full bag of water connected to the TF system were not dated. Staff U indicated the water was hung at the same time as the bottle of TF.
- The TF pump was set to deliver a water flush of 150 mL every six hours. Staff U indicated the rate was incorrect and changed it to administer 50 mL every six hours.

During concurrent observation and interview on 07/29/25 at 10:30 AM, Patient #18's husband stated that:
- Patient #18 was doing good and was well cared for until 07/22/25 when she transferred to the Progressive Care Unit (PCU, a telemetry [remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring). Overnight, she was laid too far back in the bed and coughed incessantly. He voiced concerns to the staff, but nothing was done. Some staff told him she needed to suction herself and other staff told him she just needed to cough it out.
- A speech therapist informed him that Patient #18 required suctioning because her epiglottis (a flap just above the voice box that prevents food and drink from entering the lungs) was not working properly.
- The charge nurse told him they were short staffed, and the nurse manager told him that patients in Intensive Care Unit (ICU, a unit where critically ill patients are cared for) did not have a dedicated nurse to suction them whenever they required it.
- Patient #18 was too weak to suction herself and the coughing only made her weakness worse. She was not able to get the suction tube in her mouth correctly and it would get stuck to the NG tube in the back of her throat. He suctioned her when it was needed, and he was worried she had aspirated (inhaled foreign material into the lungs).
- He pointed out a cannister on the wall and said, "look it's still there. That is what I suctioned out of her, and it looks just like her TF." The cannister contained 150 mL of a creamy brown liquid mixed with a little mucus. Half of it was a watery liquid.
- He had to insist multiple times for the TF to be turned off.
- Someone was staying with her around the clock to help suction and monitor her. He was afraid that staff would just let her die.
- Only one staff member checked the TF residual.
- The free water flush bag and bottle of TF, dated 07/26/25, had both been hanging in the room and connected to the pump since that date. On occasion, staff restarted the TF but the water had never been touched. He never observed water being administered through the NG tube.
- Patient #18 was very dehydrated (excessive loss of water from the body) and staff struggled to draw blood for laboratory testing. Her fingers, hands, arms and stomach had various shades of bruising with obvious puncture marks in the center.
- Patient #18 was finally doing better, after he insisted, they stop giving her TF at night.
- He was afraid to say too much to management for fear his wife would not be treated properly.

During an interview on 07/31/25 at 8:15 AM, Staff T, PCU Manager, stated that:
- She was unsure what an open system versus a closed TF system were and would have to reference the policy.
- TF was to be dated when hung and was only good for 24 hours regardless of how long it had been running or if it had been on hold.
- The free water flush bag was considered dated the same as the tubing and was only good for 24 hours.
- TF intake was to be documented once per shift.
- Free water flushes during medication administration were to be documented with each administration.
- Residuals were to be checked when the TF was initiated or when there were signs or symptoms of intolerance.
- She was unsure how long open bolus TF containers were kept and would have to reference the policy.
- TF supplies included plastic cups and large volume syringes. They were expected to be dated when opened and discarded after 24 hours.

Review of Patient #24's medical record, dated 07/13/25, showed she was a 63-year-old female with past history of high blood pressure and alcohol abuse. She presented to the ED with right facial droop, hemiparesis (partial paralysis affecting only one side of the body) and aphasia (an impairment in the understanding or verbalizing ideas by language, such as reading, writing, or speaking; due to injury or disorders of the brain).
- On 07/23/25 at 11:18, AM a physician order showed TF Jevity (caloric, fiber-fortified liquid nutrition) 1.5 carton (356 mL) four times a day and 25 mL of water before/after the TF bolus (large amount).
- From 07/23/25 through 07/26/25, there was no documentation of TF assessment, type, amount or residual.
- On 07/27/25 at 12:00 PM and 4:00 PM, a total of 380 mL of TF and 60 mL of water were administered.
- From 07/28/25 through 07/29/25, at 12:00 PM and 4:00 PM, a total of 380 mL of TF was administered.
- On 07/29/25 at 9:55 PM, a total of 356 mL of TF and 100 mL of water were administered.
- On 07/30/25 at 12:30 AM, documentation indicated a bolus was administered with a residual of ten mL. The TF was intermittent.
- 07/30/25 at 4:35 PM, a physician's order indicated to hold the PEG TF until cleared by GI, due to vomiting.

During concurrent observation and interview on 07/29/25 at 2:00 PM, with Staff FF, RN, in Patient #24's room showed:
- Three bottles of Jevity TF on paper towels near the sink along with an opened, undated, wet, large volume syringe.
- One bottle of TF was open with no date. Staff FF stated that he opened the bottle today. He should have put an open date on the bottle, and it was good for six hours.
- He stated Patient #24 was on intermittent TF, 380 mLs of Jevity per jejunostomy tube (J-tube, soft, flexible tube placed through the skin of the abdomen into the midsection of the small intestine) four times per day, at 6:00 AM, 11:00 AM, 4:00 PM and 10:00 PM.

During an interview on 07/29/25 at 2:15 PM, Staff GG, Nurse Manager, stated the open bottle of Jevity should have an open date and she was unsure how long the open bottle was good for.

Review of Patient #33's medical record, dated 07/19/25, showed she was a 38-year-old female
admitted through the ED after being found unresponsive. She had a history of severe alcohol abuse and was placed on a ventilator (a machine that supports breathing).
- On 7/22/25 at 1:26 PM, a physician ordered Vital AF (caloric, fiber-fortified liquid nutrition) TF, with a goal of 55 mL per hour, a 30 mL flush of water every eight hours and the dietician was to manage the TF. And OG tube was to be used for administering TF and Patient #33 was nothing by mouth.
- From 07/22/25 through 07/30/25, documentation showed missing and inconsistent types, amounts, residuals and whether the TF was being tolerated or on hold.
- From 07/24/25 through 07/27/25, there were no nutritional assessment completed by a dietician.
- On 07/28/25 at 1:34 PM, a nutritional assessment indicated Patient #33's TF was on hold and had been since 07/27/25.
- On 07/30/25 at 12:00 PM, an NG tube was placed without a physician order.

During an interview on 07/31/25 at 9:50 AM, Staff M, RN Quality, stated that there should have been an order for the NG tube placement. Staff KKK, RN Educator, had reported the TF policy did not state when to document information regarding the TF, but the standard of practice was to document every shift.

During an interview on 07/31/25 at 9:40 AM, Staff N, Chief Nursing Officer (CNO) and Staff D, Assistant CNO, stated that staff were expected to follow the hospital policy for TF. They were unsure what an open system versus a closed system was. The TF container, tubing and supplies were to be dated when opened and changed every 24 hours for both, intermittent or continuous TF. They considered the free water flush bag a part of the tubing and did not expect to see a separate date from the tubing. Residuals were to be checked upon administering TF or water flushes, and any time a patient showed signs of intolerance.

Review of the hospital's policy titled, "Medication Administration (eMAR)," revised 06/2025, showed that it was against policy to scan anything other than the armband attached to the patient in order to verify the patient's identity. Staff members found violating this policy were subject to disciplinary action.

Observation on 07/29/25 at 9:35 AM, showed Patient #18 was not wearing an identification (ID) band, but one was taped to the computer. Staff U, RN, scanned the ID band on the computer when medication was administered.

Observation on 07/29/25 at 9:10 AM, showed Staff X, Patient Care Technician (PCT), attempted to scan Patient #14's ID band. When the scanner did not work, she attempted to scan an extra ID band in the room. After multiple attempts at scanning Patient #14's ID band and the extra ID band, Staff X was able to scan the ID band on Patient #14's arm.

During an interview on 07/31/25 at 9:40 AM, Staff N, Chief Nursing Officer (CNO) and Staff D, Assistant CNO, stated that patient ID bands were to be on the patient and scanned prior to medication administration.

Review of the hospital's policy titled, "Venous Access Device Insertion, Maintenance and Removal," revised 03/2024, showed venous access device (VAD) dressings were to be:
- Changed every two days for non-transparent or gauze dressings;
- Changed every seven days for transparent dressings;
- Changed as soon as possible if the dressing was compromised; and
- VAD dressings were to be dated and initialed.

Observation on 07/28/25 at 3:00 PM, showed Patient #1's VAD dressing was not dated or initialed.

Observation on 07/28/25 at 3:15 PM, showed Patient #2's VAD dressing was not dated or initialed.

Observation on 07/28/25 at 2:15 PM, showed that Patient #5's VAD dressing was not dated or initialed.

Observation on 7/28/25 at 2:30 PM, showed that Patient #6's VAD dressing was not dated or initialed.

Observation on 07/28/25 at 2:45 PM, showed that Patient #7's VAD dressing was not initialed.

Observation on 07/28/25 at 2:50 PM, showed that Patient #9's VAD dressing was not dated or initialed.

Observation on 07/28/25 at 3:30 PM, showed that Patient #10's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 8:40 AM, showed that Patient #12's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 8:55 AM, showed that Patient #13's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 9:10 AM, showed that Patient #14's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 8:46 AM, showed that Patient #17's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 9:00 AM, showed that Patient #20's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 9:20 PM, showed that Patient #21's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 1:00 PM, showed that Patient #22's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 2:00 PM, showed that Patient #24's VAD dressing was not dated or initialed.

Observation on 07/29/25 at 1:30 PM, showed that Patient #26 had two VAD dressings that were not dated or initialed.

During an interview on 07/29/25 at 10:40 AM, Staff DD, RN, stated that VAD dressings should be dated and initialed.

During an interview on 07/31/25 at 9:40 AM, Staff N, Chief Nursing Officer (CNO) and Staff D, Assistant CNO, stated that they were unsure if all VADs should be dated and initialed but expected staff to follow the hospital policy.




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