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Based on review of 10 medical records and staff interviews, it was determined that staff failed to recognize the clinical decline of a patient and to accurately monitor and document gastric residual volumes resulting in aspiration and patient transfer to a higher level of care.

Patient #1 was diagnosed with cervical spine contusion and had a C3-C6 laminectomy and fusion on 12/26/14 at another area acute care facility. In addition the patient had a tracheostomy placement on 12/30/14 and Percutaneous Endoscopic Gastrostomy (PEG) on 3/6/15. The patient was a quadriplegic and on cervical spine precautions. The patient was discharged to the University of Maryland Rehabilitation & Orthopedic Institute for rehabilitation services on 4/8/15.

The physical examination revealed the abdomen to be soft, non-tender, non-distended and gastrostomy tube in place. The plan was to continue tube feeding with gastric residual volume and water flushes (250 ml) every 6 hours. The patient had a nutritional consult on 4/9/15 with recommendation to increase tube feeding (TF) volume from 65 ml per hour to 70 ml per hour.

Per the hospital policy and procedure, policy number 3.158, "the purpose is to establish procedural and practice guidelines for the patient requiring nutritional support via enteral feedings." The procedural guidelines state in part "all licensed nurses and nursing technicians caring for patients receiving enteral nutrition must successfully complete the appropriate competency for enteral feeding." Under section IV: Management of a Tube-Fed Patient, section D: discusses the procedure for residual volume check. Numbers 6-9 outlines the algorithm for gastric residual volumes as follows:
6. If GRV (Gastric Residual Volume) is < 250 ml re-feed aspirate and continue tube feeding in patients without other clinical changes such as nausea, vomiting, bloating, abdominal discomfort, constipation or respiratory compromise.
7. If GRV is 250 ml - 350 ml re-feed aspirate in patients without clinical changes or change in GI exam. If changes noted hold tube feeding for 1 hour and re-check residual volume.
8. If the GRV is > 350 ml or patient experiences emesis, hold tube feeding, discard aspirate, notify the physician, and document in medical record. Persistent high residual volumes may require treatment with a pro-motility agent, feeding tube advancement post-pylorically or a change in formula.
9. Is an algorithm for checking GRV every 6 hours if patient is receiving gastric tube feeding, and document all residuals on the patient's flowsheet.

Review of patient #1's medical record revealed residual volumes of zero with one 12 ml and one 40 ml through 4/20/15. Per nursing progress note on 4/19/15 at 7:44 pm, patient #1 was anxious and frequently called staff to check on her. The house officer was called, patient assessed and received a new order for valium. The PEG tube was intact. The patient complained of nausea and received Zofran with relief. The nurse assuming care of patient #1 on 4/20/15 at 7:30 am noted the patient's gown was soiled with spilled tube feeding. The patient complained of nausea and tried to vomit, but unable. After she was cleaned following incontinence of stool she requested to be taken "to the hospital down town." At 9:12 am the patient's vital signs were temperature 102.7 degrees (F), heart rate 118, blood pressure 107/74, respirations 21 with oxygen saturation at 95%. The house officer was paged at 9:13 am. The Patient Care Assistant (PCA) called the nurse to patient #1's room where it was noted that the patient was not responding (although it did not appear that she ever became pulseless), and a code blue was activated at 9:15 am. The staff responded to a code blue with patient awake and mouthing words and being bagged by the respiratory therapist. The PEG was connected to drain, foley to drain, IV access initiated and EKG done before the patient was transferred to ICU. At 10:55 am while in ICU the patient continued to mouth words. She was on 50% oxygen via trach collar which was changed to 100%. The patient's PEG drained 900 mls and another 300 mls with low intermittent suction. The plan was to send the patient back to the University of Maryland Medical Center Shock Trauma Center (UMMC/STC).

Per a note dated 4/20/15 at 12:00 pm by the intensive care provider the patient was deep tracheal suctioned for extensive tube-feeding like liquid. Gastric decompression yielded at least 1-Liter of fluid. Her chest x-ray showed bilateral patchy lung opacities and AICD. The assessment and plan was pulmonary aspiration with respiratory arrest and acute lung injury. There was concern for developing Acute Respiratory Distress Syndrome (ARDS) given low PO2/FI02. The patient was to be closely monitored for clinical worsening that would warrant transfer back to UMMC/STC. The patient was eventually transferred to UMMC/STC for hypotension requiring medication to maintain pressure.

Patient #1's diagnoses and limited mobility prevented her from self-positioning to prevent aspiration if she vomited. The patient complained of nausea and the urge to vomit. There was a question regarding the accuracy of her gastric residual volumes (GRV) which were recorded every 6 hours. Until her transfer to ICU the patient's GRVs were recorded as zero, 12 ml and 40 ml. As the patient declined, deep tracheal suctioning revealed tube-feeding like liquid, and prior to transfer she had a total of 1200 ml from gastric decompression and PEG tube to low suction. The decline in gastric motility and absorption should have been detected during the gastric residual volume checks. The volume of gastric contents could easily potentiate vomiting and aspiration as in the case of patient #1. As a result patient #1 became septic.