HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that the CAH (Critical Access Hospital) failed to ensure a Quality Assurance program identified and assumed preventative measures to decrease the potential for problems and failed to integrate radiology services when necessary.

Findings include:

1. An onsite complaint investigation was conducted on survey date 02/08/11. An 82 yr old male presented to the ED from a nursing home (NH) to have a gastrostomy tube (G-tubes) reinserted. The RN inserted the #16 Fr Foley catheter into the abdominal stoma per MD order and the patient was transported back to the NH. There was no documented radiographic evidence that the G-tube was confirmed to be in the abdomen.

2. The DON indicated on survey date 02/08/11 that Radiology was not called out to confirm the G-tube placement. "This patient has a history of pulling out his feeding tube and the radiology department was not working at the time." "We have no policy and procedure developed for the insertion/reinsertion of G-tubes in the ED."