HospitalInspections.org

Based on medical record review, staff interview and document review, it was determined the facility staff failed to provide enteral feeding via the correct tube (Patient # 15) for one (1) patient requiring enteral feeding.

The findings include:

In a written complaint to the State Agency, the complainant advised that staff of the facility provided enteral feeding to Patient #15 through the incorrect tube (the G tube).

On 3/6/23 at 2:30 p.m., a review of the medical record of Patient #15 (P15) was conducted. The medical record review revealed that P15 had a gastro-jejunal (GJ tube). A GJ tube is surgically inserted directly into the stomach with a port that extends through the duodenum and terminates in the jejunum of the small intestine. The gastric port (G tube) is used to decompress the stomach and the J tube is used to administer feedings (Torigan, 2017).

On 3/7/23 at 9:00 a.m., an interview was conducted with Staff Member #39 (S39). S39 stated that they remembered that P15 had chronic aspiration issues and was hospitalized because tube feedings were going into the patient's lungs. P15 had a gastro-jejunal (GJ tube). Apparently, P15 was fed through the G-tube and should have been fed through the J-tube. Once it was discovered, S39 discussed it with P15's assigned nurse. S39 said that the nurse thought it may have been switched by another nurse while they were off the floor but was unsure how it occurred. The nurse told S39 that P15 did not encounter any issues while being fed through the G-tube. The feedings were switched to the correct ports and the assigned nurse said that they were going to label the ports so that it did not occur again. S39 did not remember the name of the nurse that they spoke with.

On 3/7/23 at 9:50 a.m., S1 was asked why the error with P15's tube feeding was not reported as an adverse event. S1 stated that staff are encouraged and trained to report near misses, adverse events etc. in the new patient safety reporting system, but reporting is voluntary. S1 stated that the event may not have been reported because there was no harm done to P15 and the nurse resolved the issue right away by labeling the tubes. S1 stated there was not a policy to speak to the patient safety reporting system, but there were guidelines.

Based on medical record review, staff interview and facility document review, it was determined the facility staff failed to perform neurological checks as ordered by the provider for one (1) of three (3) patients sampled for ordered neurological assessments (Patient #5).

The findings include:

On 3/6/23, the surveyor reviewed three (3) ED medical records with SM #18 assisting with navigation. The three (3) medical records were of patients who presented to the emergency department (ED) with possible neurological deficit symptoms. The documentation and monitoring of neurological status, specifically performing neuro checks, was included as part of the review.

The medical record for patient #5 contained the following order, to start on 1/22/23 at 2:43 a.m.: "Neurologic Check: Monitor... Status: Active... Comment: Assess neurologic status 2qh [every 2 hours] for the first 24 hours, then q4h [every 4 hours] if stable".

Patient #5's ED medical record contained the following completed neuro checks:

1/22/23 at 10:46 a.m.
1/22/23 at 6:37 p.m.
1/23/23 at 9:00 a.m.

During the twenty-four (24) hour timeframe of the above referenced order (1/22/23 at 2:43 a.m. to 1/23/23 at 2:43 a.m.), there were only two (2) neuro checks documented.

A physician order-set titled, Seizure/Epilepsy Admission, was reviewed. The order-set was used by the provider to enter the above referenced order for neurological monitoring. The order-set document reads, in part: "...Neurologic Check: Monitor... Priority: R Date: Today Time: NOW... Frequency: Other... Comment: Assess neurologic status 2qh for the first 24 hours, then q4h if stable...". There is a box next to the order that was marked with a "X".

A review of the facility's document titled, Assessment and Reassessment of ED Patients, was conducted and reads, in part: "...Reassessment - A process of periodic re-evaluation based on the patient's chief complaint, acuity, condition, and symptoms of treatments. Frequency of reassessment performed for patients during the course of their treatment may be determined by the patient's chief complaint, acuity, condition, symptoms, treatments and orders...".

The concerns were discussed with Staff Members #14, #15, #18, #32 and #33 in the morning of 3/7/23, as well as with Staff Members #1, #3, #4 at the time of exit conference on 3/7/23 at 1:00 p.m.