HospitalInspections.org

Based on document review and interview, the hospital failed to ensure patient care was assigned in accordance with professional standards and/or competence of the nursing staff for 1 of 1 patients requiring placement of a nasogastric tube (NG/NGT) in the Emergency Department (ED).

Findings include:

1. a. Review of the hospital policy, "ED 1 Scope of Service", Reviewed 11/2020, indicated the following: Standards of Practice: The ENA (Emergency Nurses Association)...standards are references used in the formulation and review of policies, procedures and standards of practice in the Emergency Department.

b. Review of Gastric Tube Placement Verification professional standards by the Emergency Nurses Association (ENA), 2018, indicated the following:
Incorrect Gastric Tube (GT) placement can result in serious and even lethal complications... The standard of care requires verification of the GT placement... Radiographic verification is the preferred method of confirmation... This Clinical Practice Guideline (CPG) aims to evaluate various bedside gastric tube placement verification methods as an alternative to radiography.
Description of Decision Options/Interventions and the Level of Recommendation: Note; the verification methods were rated as follows: A = High (consistent and good quality of evidence), B = Moderate (some inconsistencies in quality); C = Weak (limited or low-quality patient-oriented evidence); N/R = Not recommended; I/E = Insufficient evidence upon which to make recommendation; N/E = No evidence upon which to make recommendation.
A - Radiographic examination [X-Ray or CT (computed tomography) scan] remains the gold standard...;
B - Use of pH testing of gastric tube aspirates... and Bedside ultrasound
C - Carbon dioxide detection and gastric lipase testing
N/R - Use of auscultation as a single verification method is unreliable
I/E - Transillumination and magnetic detection requires equipment that may be difficult to obtain

c. Review of professional guideline documentation from Cinahl (Cumulated Index to Nursing and Allied Health Literature), titled "Nursing Practice & Skill - Nasogastric Tube: Inserting and Verifying Placement in Adult Patient", May 12, 2017, indicated the following:
Review the patient's medical history/medical record for history of any related surgery or injury to the...stomach...
Note: The length of the tube inserted into the patient should be recorded in the patient's chart in the event the tube becomes dislodged or there is suspicion that the tube has migrated from the stomach.
Follow facility/unit-specific protocol to verify correct placement of the NGT (nasogastric tube). Some commonly used methods include: Radiographic verification... Radiographic confirmation is the most definitive method of establishing placement... Aspiration for visual check and pH analysis: Check gastric contents visually...a pH < or = to 4.0 is usually indicative of gastric acid... AACN (American Association of Critical Care Nurses) recommends that a variety of methods be used to confirm NGT placement.
Red Flags: Insertion and removal of an NGT from patients recovering from gastric...surgery should be limited to advance practice clinicians and physicians due to the risk of interrupting a suture line.

2. The MR of patient P5 indicated the patient presented to the ED on 11/24/20 at 11:26 hours. The "Nurses" Clinical Report indicated the following: Chief Complaint: Body aches. Problems: Allergic Rhinitis...Bariatric Surgery... At 20:07 (hours) on 11/24/20 and entry by Registered Nursing (RN) N1, indicated the following: 16 fr (French) NG (nasogastric) tube inserted in left nostril with minimal difficulty. Placement confirmed by return of gastric contents. Return yellow fluid. Tube secured. Patient tolerated procedure well... . The MR lacked documentation of radiographic or pH testing of gastric tube aspirates as verification of NG tube (NGT) placement. The MR lacked documentation of the length of the tube inserted into the patient. The MR lacked documentation of an advanced practice clinician or physician having placed the gastric tube.

3. Review of personnel files lacked documentation of N1 having been observed for competency of NGT placement.

4. On 10/26/21, beginning at approximately 11:00 AM, A1, Administrator/Chief Nursing Officer (CNO), indicated the facility/ED followed the Cinahl and ENA guidelines provided by him/her for NGT placement. A1 verified the hospital/ED did not have their own policy/procedure for NGT placement. Beginning at approximately 3:45 PM, A1 verified the personnel file of N1 lacked documentation of observed competency for NGT placement.

Based on document review and interview, the hospital failed to ensure for an accurately written medical record (MR) for 3 of 10 patients (P5, P7 and P10).

Findings include:

1. Review of the hospital policy, "HIM 6.6 Completion of Medical Records", Reviewed 8/2020, indicated all medical record entries, including handwritten and electronic, must be legible, complete and accurate.

2. a. The MR of patient P5 indicated the patient to be male gender. The Clinical Report - Physicians/Mid Levels indicated the following: Has not recently been "camping" or on antibiotics... Review of systems: No fever, muscle aches, difficulty with urination, missed periods or headache.

b. The MR of patient P7 indicated the patient's gender to be male. The Clinical Report - Physicians/Mid Levels indicated the following in Review of Systems: No enlarged lymph nodes, missed periods or abnormal bleeding. Denies current pregnancy.

c. The MR of patient P10 indicated the following: The Clinical Report - Nurses indicated the patient left the ED without completion of treatment. MR documentation included a signed AMA (against medical advice) form. The Clinical Report - Physicians/Mid Levels indicated the following: Disposition: Admitted to Medical/Surgical. Discharged. Condition: good and stable. The MR lacked documentation of an addendum or correction to the physician's note for patient disposition.

3. On 10/26/21, beginning at approximately 12:45 PM, A1, Administrator/Chief Nursing Officer (CNO), verified MR findings of patient P5. Beginning at approximately 2:00 PM, A1 verified MR findings of patient P7 and that the patient was male. A1 also verified the MR of patient P10 contained conflicting and inaccurate documentation of patient final disposition.