HospitalInspections.org

Based on document review and interview, the facility failed to ensure a Registered Nurse followed facility policy related to nasogastric tube assessments for 1 of 10 patient medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Assessment and Reassessment" with an approval date of 5/3/23, indicated the following: POLICY: 1. To ensure that the needs and problems of each patient are identified and assessed upon admission and throughout the patient's hospital stay, a Registered Nurse shall identify patient needs and determine their priority by interpreting patient data that is collected continuously. 2. A. Best practice is to document assessment, interventions, purposeful rounding, and vital signs in real time. Attachment A. Scope of Assessment and Reassessment by Patient Care Unit. Medical Surgical. Elements Assessed: 3. IV Lines, tubes and drains. Time Frame: 3. IV heplock, lines, drains and tubes every 4 hours/IV infusing every 2 hours.

2. Facility procedure titled "Nasogastric or orogastric tube irrigation", revised 12/11/23, indicated the following:
Implementation: Confirm proper placement of the NG (nasogastric) or OG (orogastric) tube using at least two bedside techniques: * Observe the incremental marking on the tube at the exit site or measure the external tube length and compare it with the incremental marking or external length documented in the medical record at the time of insertion to assess for tube migration. * Review chest X-ray reports for notations about the tube's location. *Inspect the visual characteristics of the tube aspirate. Fasting gastric secretions commonly appear grassy green, brown or clear and colorless. *If tube placement remains uncertain, notify the practitioner and arrange for an X-ray as ordered.

3. Review of Patient #1's medical record indicated the following:
(A) The patient was admitted inpatient on 9/10/24 at 2:00 p.m. with a diagnosis of ventral hernia and discharged on 9/15/24 at 5:00 p.m.
(B) The patient had a nasogastric tube placed in the right nostril on 9/11/24 at 8:04 p.m. and it was discontinued on 9/14/24 at 5:16 p.m. per physician order. Patient #1's medical record lacked documentation of a nasogastric tube assessment and/or placement verification every four hours per facility policy on the following dates and times: 9/12/24 at 4:05 a.m., 8:05 a.m., 11:14 a.m., 3:14 p.m., 7:14 p.m., 8:05 p.m., 9/13/24 at 12:00 a.m., 4:05 a.m., 8:05 a.m., 12:05 p.m., 4:05 p.m., 8:00 p.m., 9/14/24 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 11:00 a.m. 3:00 p.m.

4. During an interview with A3 (5 Orthopedic Unit Supervisor) and A5 (Clinical Informatics) on 10/16/24 at 2:00 p.m., they verified the medical record information for Patient #1 and the lack of NG assessment documentation and/or NG placement verification every 4 hours.

5. During an interview with A1 (Director of Accreditation) on 10/16/24 at 3:30 p.m., A1 indicated that NG placement verification should be completed with NG assessments and documented in the patient's medical record.