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Based on review of facility policy and procedure, medical record review, and staff interview, nursing staff failed to assess and document gastric residual volume in patients receiving tube feeding per policy in 2 of 2 sampled patients (Patient's #1, #2)

The findings included:

Review on 01/24/2018 of the policy and procedure titled "Gastric /Duodenal Tube" revised date: 01/01/2018 revealed "...4. Residuals: Check Gastric Residual Volume (GRV) every 4 hours. If GRV is < {less than} 400 ml {milliliter} 1. Refeed/re-instill up to 200 ml and discard the excess; 2. Continue tube feeding at same rate ... Excess residual that is discarded is documented as output".

Open medical record review of Patient #1 revealed a 70-year-old male admitted to (Name of facility) on 04/09/2018 for acute on chronic hypoxic hypercarbic failure, acute on chronic heart failure, adult failure to thrive syndrome, and ALS (amyotrophic lateral sclerosis). Review of the history and physical (H&P) revealed Patient #1 was admitted with PEG (percutaneous endoscopic gastrostomy) tube placement for feeding purposes. Review of the "24 Hour Patient Record and Plan of Care" dated 04/19/2018, 04/20/2018, and 04/21/2018 revealed no residual amount documented in three consecutive days. Additional review of the "24 Hour Patient Record and Plan of Care" dated 04/22/2018 revealed the residual amount was recorded as 0 ml at 1000; and on 04/23/2018 at 2200, the residual was recorded as 0.

Interview on 04/25/2017 at 1120 with NA #1 revealed the tube feeding had to be turned off prior to providing personal care to prevent aspiration.

Interview on 04/25/2017 at 1410 with RN #1 revealed when caring for patient on tube feeding, the head of the bed had to be elevated at 30 to 40 degrees, check residuals every 4 hours and if residuals remained elevated to turn off the tube feeding and notify the physician.

Interview on 04/25/2017 at 1535 with RN #2 revealed RN #2 was instructed to check the tube feeding site and residual amount every 4 hours. Additional interview revealed nurse had to also check the setting of the tube feeding pump with each assessment. Further interview revealed if the residual was greater than 400 more than once, recheck the residual in one hour and notify the physician.

Interview on 04/27/2018 at 1040 with Nurse Leadership revealed nurses are required to check and document residuals q (every) 4 hours. Interview revealed the policy in regards to documentation of tube feeding assessment was not followed. Further interview revealed there has been reeducation in regards to tube feeding assessment/documentation of tube feeding.

Closed medical record review of Patient #2 revealed a 71-yeal-old male with a remote history of esophageal cancer. Patient #2 was admitted to (Name of facility) on 02/14/2018 for acute on chronic respiratory failure with a history of coronary artery disease, CVA (stroke), deconditioning and arterial fibrillation. Review revealed Patient #2 was on continuous tube feeding with Jevity 1.5 at 65 ml/hour. Review of the Review of the "24 Hour Patient Record and Plan of Care" dated 03/01/2018 revealed no gastric residual amount documented and on 03/02/2018 the gastric residual amount was assessed and documented at 0945, at 1300 and at 1800. Review revealed on 03/03/2018 the gastric residual amount was assessed and documented as 0 ml at 1130, 1400, 1630 and 2200. On 03/04/2018 the gastric residual amount was assessed and documented (time and amount unknown) three times and as 0 ml at 2250. On 03/05/2018 the gastric residual amount was assessed and documented (time and amount unknown) four times. On 03/06/2018 revealed the gastric residual amount was assessed three times with time and amount unknown. Review of the discharge summary dated 03/06/2018 revealed Patient #2 was noted to have some abdominal distention and some contents of what appeared to be tube feeding had come though the patient's tracheostomy tube (incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea).

Interview on 04/25/2017 at 1120 with NA #1 revealed the tube feeding had to be turned off prior to providing personal care to prevent aspiration.

Interview on 04/25/2017 at 1410 with RN #1 revealed when caring for patient on tube feeding, the head of the bed had to be elevated at 30 to 40 degrees, check residuals every 4 hours and if residuals remained elevated to turn off the tube feeding and notify the physician.

Interview on 04/25/2017 at 1535 with RN #2 revealed RN #2 was instructed to check the tube feeding site and residual amount every 4 hours. Additional interview revealed nurse had to also check the setting of the tube feeding pump with each assessment. Further interview revealed if the residual was greater than 400 more than once, recheck the residual in one hour and notify the physician.

Interview on 04/27/2018 at 1040 with Nurse Leadership revealed nurses are required to check and document residuals q (every) 4 hours. Interview revealed the policy in regards to documentation of tube feeding assessment was not followed. Further interview revealed there has been reeducation in regards to tube feeding assessment/documentation of tube feeding.


NC00137075