HospitalInspections.org

Based on policy and procedure review, medical record review, observation, and staff interviews, the facility staff failed to maintain aspiration precautions as per hospital policy for 6 of 6 sampled patients (#7, #14, #16, #17, #18, #19); and failed to flush feeding tube as ordered and as per hospital policy for 1 of 1 sampled patients (#7.

Findings include:

A. Review of hospital's policy and procedure titled "Enteral (a way to provide food through a tube placed in the nose, the stomach, or the small intestine) Nutritional Support for Adults", current effective date 07/10/2015, revealed "...Aspiration (the accidental sucking in of food or fluid into the lungs) precautions are maintained on patients receiving tube feedings...Elevate head of bed at 30-45 degrees during feeding...Tube feeding is placed on hold when patient is placed less than 30 degrees in bed...".

1. Open medical record review on 09/15/2015 of Patient #16's "HISTORY AND PHYSICAL", dictated 08/26/2015 at 1742, revealed a 73 year old male admitted on 08/26/2015 with a "CHIEF COMPLAINT" of Altered mental status (a disruption in how the brain works that causes a change in behavior) ...". Further medical record review revealed the patient was receiving continuous tube feedings through a NG (nasogastric; a thin, plastic tube that is inserted through the nostril, down the esophagus (muscular tube that connects the throat to the stomach), and into the stomach) tube.

Observation of Patient #16 on 09/15/2015 at 1540 revealed the patient was asleep, lying supine (flat on back) with head and body curving to the left. Observation revealed tube feeding was actively infusing through an NG tube via a feeding pump. The patient's head of bed was observed to be elevated 20 degrees per the angle degree indicator on the bed's side rail. Observation revealed the head of the patient's bed was 10 to 25 degrees lower than required during feeding, per the hospital's policy, to prevent aspiration.

Interview with Registered Nurse (RN) #1 on 09/15/2015 at 1540 revealed aspiration precautions include "head of bed up at least 30 degrees." RN #1 stated she just looks at the patient in the bed to see how high the patient's head is. RN #1 was directed to the angle indicator on the side rail of Patient #16's bed. RN #1 confirmed the head of the patient's bed was at 20 degrees. RN #1 stated, "I guess we always underguess the degree."

Interview with Nurse Manager (NM) #2 on 09/15/2015 at 1542 revealed, "If they (patients) are tube fed, head of bed needs to be 30 degrees or higher."

2. Open medical record review on 09/15/2015 of Patient #14's "HISTORY AND PHYSICAL", dictated 09/03/2015 at 1626, revealed a 64 year old male admitted on 09/03/2015 with a "CHIEF COMPLAINT" of "History of fall...ASSESSMENT 1. Multiple falls secondary to worsening Parkinson disease (a progressive, degenerative disorder of the brain and nerves that affects movement) versus dehydration (the body does not have enough water and fluids to carry out its normal functions). Electronic medical record review revealed a PEG tube (percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach) was placed on 09/11/2015 due to failure to thrive (failure to gain weight as expected or inappropriate weight loss). Further medical record review revealed a physician's order dated 09/12/2015 at 1012 "Jevity 1.2 (a tube feeding nutrition solution)...20 continuous, goal of 60 ml (milliliters)/hr (hour) continuous...".

Observation of Patient #14, on 09/15/2015 at 1200, revealed the patient was awake, lying supine in bed with tube feeding actively infusing via a tube feeding pump. The patient's head of bed was observed to be elevated at 20 degrees per the angle degree indicator on the bed's side rail. Observation revealed the head of the patient's bed was 10 to 25 degrees lower during feeding than required, per the hospital's policy, to prevent aspiration.

Interview with Nurse Manager (NM) #2 on 09/15/2015 at 1542 revealed, "If they (patients) are tube fed, head of bed needs to be 30 degrees or higher."

3. Open medical record review on 09/15/2015 of Patient #18's "HISTORY AND PHYSICAL", dictated 09/10/2015 at 1926, revealed a 63 year old male admitted on 09/10/2015 with a "CHIEF COMPLAINT" of "Abdominal distension and vomiting." Further medical record review revealed the patient had a PEG tube in position prior to admission.

Observation of Patient #18 on 09/15/2015 at 1210, revealed the patient was awake, lying supine in bed with tube feeding actively infusing via a tube feeding pump. The head of the patient's bed was observed to be elevated 20 degrees per the angle degree indicator on the bed's side rail. Observation revealed the head of Patient #18's bed was 10 to 25 degrees lower during feeding than required, per the hospital's policy, to prevent aspiration.

Interview with Nurse Manager (NM) #2 on 09/15/2015 at 1542 revealed, "If they (patients) are tube fed, head of bed needs to be 30 degrees or higher."

4. Open medical record review on 09/15/2015 of Patient #19's "HISTORY AND PHYSICAL", dictated 07/08/2015 at 1017, revealed a 60 year old male patient admitted on 07/08/2015 with a "CHIEF COMPLAINT" of "Fever...ASSESSMENT AND PLAN...The patient has gastrostomy (a tube inserted through the abdomen that delivers nutrition directly to the stomach) tube feeds...".

Observation of Patient #19 on 09/15/2015 at 1212, revealed the patient was awake, lying supine in bed with tube feeding actively infusing via a tube feeding pump. The head of the patient's bed was observed to be elevated 20 degrees per the angle degree indicator on the bed's side rail. Observation revealed the head of Patient 19's bed was 10 to 25 degrees lower during feeding than required, per the hospital's policy, to prevent aspiration.

Interview with Nurse Manager (NM) #2 on 09/15/2015 at 1542 revealed, "If they (patients) are tube fed, head of bed needs to be 30 degrees or higher."

5. Open medical record review on 09/15/2015 of Patient #17's "HISTORY AND PHYSICAL", dictated 09/02/2015 at 0034, revealed a 75 year old female admitted on 09/01/2015 with a "CHIEF COMPLAINT" of "Altered mental status and drowsiness." Electronic medical record review revealed a PEG tube was placed on 09/12/2015.

Observation of Patient #17, on 09/15/2015 at 1214, revealed the patient was asleep, lying supine in bed with tube feeding actively infusing via a tube feeding pump. The head of Patient #17's bed was observed to be at 20 degrees per the angle degree indicator on the bed's side rail. Observation revealed the head of the patient's bed was 10 to 25 degrees lower during feeding than required, per the hospital's policy, to prevent aspiration.

Interview with Nurse Manager (NM) #2 on 09/15/2015 at 1542 revealed, "If they (patients) are tube fed, head of bed needs to be 30 degrees or higher."

6. Closed medical record review on 09/15/2015 through 09/18/2015 of Patient #7 revealed a 78 year old male who presented to the facility's Emergency Department, on 05/09/2015 at 1104, via ambulance from home. Patient #7's "HISTORY AND PHYSICAL", dictated 05/09/2015 at 1716, revealed the patient was admitted on 05/10/2015 with a "CHIEF COMPLAINT/REASON FOR HOSPITALIZATION" of "Nausea and vomiting, abdominal (belly) distention (swollen from internal pressure) for the last 24 hours...IMPRESSION...partial to complete small bowel (long, continuous tube that runs from the stomach to the large intestines) obstruction (blockage) versus ileus (obstruction of the bowel due to it being inactive or paralyzed where food cannot move through) and sepsis (a potentially life-threatening complication of an infection) secondary to that...Chronic debility (the state of being weak, feeble) with advanced Alzheimer dementia (a progressive disease that destroys memory and other important mental functions) dementia. Patient is bed-bound...Patient was on hospice care (end-of-life care with the goal of the care to help people who are dying have peace, comfort and dignity). Further record review indicated the patient had a Dubhoff (a small-bore, flexible NG feeding tube) placed on 06/01/2015 with tube feeding initiated on 06/01/2015. Further review of Patient #7's electronic record revealed an order dated 06/18/2015 at 0806 "NURSING ORDER aspiration precautions." Medical record review revealed Patient #7 had a gastrojejunostomy (a small feeding tube that is surgically placed in the stomach and small intestine) on 07/20/2015. A physician's order on 07/21/2015 at 1715 revealed, "Resume feeding via Jejunal port only. Glucerna 1.5 (a tube feeding nutrition solution) @ (at) 20ml/hr...".

Review of the electronic Nursing "Clinical Notes" documentation revealed, a note for 06/18/15 at 1243 indicating the patient's HOB (head of bed) was at 26 degrees (4 to 19 degrees lower than required by hospital policy to prevent aspiration). Further review of nursing documentation revealed a note on 07/24/2015 at 0804 HOB at 28 degrees (2 to 17 degree lower than required by hospital policy to prevent aspiration); on 07/25/2015 at 0952 HOB at 28 degrees; on 07/29/2015 at 0945 HOB at 28 degrees; on 07/30/2015 at 0959 HOB at 28 degrees. Multiple nursing notes throughout the patient's hospital stay indicated Patient #7's HOB was elevated, but did not indicate the degree of elevation.

Interview with RN #11, on 09/17/2015 at 1400, confirmed the electronic nursing documentation revealed the head of Patient #7's bed was lower than 30 degrees.

B. Review of hospital's policy and procedure titled "Enteral (a way to provide food through a tube placed in the nose, the stomach, or the small intestine) Nutritional Support for Adults", current effective date 07/10/2015, revealed "...Dobhoff Tube - small bore enteral feeding tube...Tubes are flushed with 30mL (milliliters) water every three (3) hours to maintain patency...".

Closed medical record review on 09/15/2015 through 09/18/2015 of Patient #7 revealed a 78 year old male who presented to the facility's Emergency Department, on 05/09/2015 at 1104, via ambulance from home. Patient #7's "HISTORY AND PHYSICAL", dictated 05/09/2015 at 1716, revealed the patient was admitted on 05/10/2015 with a "CHIEF COMPLAINT/REASON FOR HOSPITALIZATION" of "Nausea and vomiting, abdominal (belly) distention (swollen from internal pressure) for the last 24 hours...IMPRESSION...partial to complete small bowel (long, continuous tube that runs from the stomach to the large intestines) obstruction (blockage) versus ileus (obstruction of the bowel due to it being inactive or paralyzed where food cannot move through) and sepsis (a potentially life-threatening complication of an infection) secondary to that...Chronic debility (the state of being weak, feeble) with advanced Alzheimer dementia (a progressive disease that destroys memory and other important mental functions) dementia. Patient is bed-bound...Patient was on hospice care (end-of-life care with the goal of the care to help people who are dying have peace, comfort and dignity). Further record review indicated the patient had a Dubhoff placed on 06/01/2015 with tube feeding initiated on 06/01/2015. Medical record review revealed Patient #7 had a gastrojejunostomy (JG tube) (a small feeding tube that is surgically placed in the stomach and small intestine) on 07/20/2015.

Review of electronic medical record for Patient #7 revealed a physician's order for "Intake & Output ROUTINE" dated 05/09/2015 at 1709. Further review of physician's orders revealed "Pour free water 100 cc (cubic centimeter - a volume of measurement equal to one milliliter) q (every) 8 hr (hours) per Dubhoff" on 06/06/2015 at 1653; "Increase free water per Dubhoff to 200 cc q 6 hrs" on 06/07/2015 at 1622; "...Increase free water flushes to 250 ml (milliliters) Q 6hrly (hourly)" on 06/28/2015 at 1450; "...water flushes 250 ml Q 6 hours..." at 07/21/2015 at 1715; "...125 mL free water q3h (every 3 hours) via JG tube" on 07/23/2015 at 1334.

Further review of Patient #7's electronic medical record revealed no documentation of water or water flushes was present in the patient's intake and output record or the nurse's clinical notes for 06/04/2015, 06/05/2015, and 06/06/2015. Nursing documentation on 06/06/2015 at 2145 revealed the feeding tube was "clogged." The total volume of flushes documented for 06/07/2015 was 650 ml (150 ml less than ordered). 530 ml of flushes were recorded for 06/08/2015 (270 ml less than ordered). No documentation of flushes was present for 06/09/2015 (800 ml less than ordered). The total amount of flushes recorded on 07/04/2015 was 600 ml (400 ml less than ordered). Further review revealed a nurse's clinical note on 07/05/2015 at 0631 that reported "Dubhoff stopped up."

Interview with RN #11, on 09/17/2015 at 1400, confirmed the nursing staff were not documenting Patient #7's feeding tube flushes as ordered.

Interview with LD (Licensed Dietitian) #6, on 09/18/2015 at 0940, Dubhoffs don't usually get clogged with feedings. Medications that are administered are the biggest problem. "If they are flushed properly they usually don't get clogged."

NC00110042, NC00109745, NC00108850