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A. Based on document review and interview, it was determined that for 2 of 2 records reviewed (Pts. #3 and #10) for enteral (delivered to stomach/small intestine through a tube) feeding administration, the Hospital failed to ensure that tube feedings were administered without delay and as ordered.

Findings include:

1. The Hospital's policy titled, "Enteral Feedings" (revised 02/2025) was reviewed and required, "Policy: Enteral Nutrition and Parenteral [administered intravenously] Nutrition solutions are available upon physician's order. Purpose: To provide nourishment to patients who are unable to orally meet their nutritional needs... Enteral nutrition orders should include: Product's name; Rate (cc/hr) [milliliters per hour]; Strength, and Infusion schedule (continuous, cyclic, intermittent, bolus)..." The Hospital could not provide a policy for enteral feedings effective prior to 02/2025.

2. The clinical record of Pt. #3 was reviewed. Pt. #3 presented to the ED on 01/28/2025, with a chief complaint of respiratory concerns. The Medical Screening Exam, dated 02/18/2025, indicated that the decision to admit Pt. #3 to the ICU (intensive care unit) was made on 01/28/2025 at 9:45 AM.

- The Dietician Evaluation, dated 01/28/2025 at 2:58 PM, included " ...Patient triggers a consult due to TF [tube feeding] ...Nutritional Diagnosis: Inadequate protein/energy intake related to decreased ability to consume sufficient protein and/or energy as evidence by estimated energy intake from diet less than estimated recommended levels ... Nutrition Prescription: ... Diet: NPO [nothing by mouth] ... Recommend starting patient on Vital [tube feeding formula] ... at 15 ml/hr [milliliters per hour] continuous, advance as tolerated by 10 ml Q4 [every 4 hours] to reach the goal rate of 65 ml/hr continuous with FWF [free water flushes]: 90 ml Q4 or per MD ..."

- A physician's order was placed on 01/28/2025 at 3:07 PM to start the Vital HP tube feeding as recommended by the dietician.

- ED Nursing Notes from 01/28/2025-01/29/2025 were reviewed and indicated that they (staff) could not find a feeding pump to start the tube feedings for Pt. #3.

- The record indicated that Pt. #3 was transferred to the ICU on 01/29/2025 at 8:09 AM.

- Enteral Feeding Administration Records from 01/28/2025-02/04/2025 were reviewed and indicated that tube feeding was initiated on 01/29/2025 at 8:00 PM (nearly 29 hours after tube feeding was ordered) and was started at a rate of 10 ml/hr (not 15 ml/hr as ordered). The record lacked documentation as to why tube feedings were delayed on 01/29/2025 when the patient was transferred to the ICU (day shift).

3. The clinical record of Pt. #10 was reviewed. Pt. #10 was admitted on 04/08/2025 with a diagnosis of possible stroke.

- The Dietician (E#15) Evaluation, dated 04/09/2025 at 7:57 AM, included "...Patient triggers consult due to TF... Nutritional Diagnosis: ...Inability to consume orally related to stroke/dysphagia [difficulty swallowing] as evidence by need for enteral nutrition... Nutrition Interventions: ...Diet: NPO... Recommend starting patient on Jevity 1.5 [tube feeding formula] at 30 ml/hr continuous, advance as tolerated by 10 mL Q4 to reach the goal of 45 ml/hr continuous with FWF: 130 ml Q4 or per MD..."

- A physician's order was placed on 04/09/2025 at 8:09 AM to start the Jevity tube feeding as recommended by the dietician.

- Enteral Feeding Administration and Intake records from 04/09/2025-04/14/2025 were reviewed and indicated that the tube feeding was initiated on 04/09/2025 at 10:00 PM (nearly 14 hours after the tube feeding was ordered) and was started at a rate of 40 ml/hr (not 30 ml/hr as ordered). The record lacked documentation as to why tube feedings were delayed on 04/09/2025. Additionally, the record lacked documentation that tube feedings were administered as ordered on 04/12/2025 and 04/13/2025 and did not include any documentation to indicate why feedings were not administered as ordered.

4. An interview was conducted with Dietician (E#15) on 04/15/2025, at approximately 1:00 PM. E#15 stated that to maintain Pt. #3's nutritional needs, they placed orders to start the patient on tube feedings. E#15 did not recall being notified that there were no feeding pumps available for this patient. E#15 stated that they generally have enough feeding pumps, and they will check central supply and all the units to find a pump. E#15 stated that once in a while a patient in the ED will need a feeding pump so don't usually keep any on hand in the ED. E#15 stated that they may or may not start the feeding in the ED, depending on how long the patient stays in the ED, even after being admitted. E#15 stated that if they are only going to be there for an hour, they may not start it right away. E#15 stated that if it was reported to E#15 that staff didn't have a feeding pump available to start the tube feeding, E#15 could have ordered bolus feedings for the patient in the meantime.

5. An interview was conducted on 04/16/2025 at approximately 9:15 AM with the ICU Nurse (E#13) who was assigned to work with Pt. #3 on the morning of 01/29/2025 when Pt. #3 was transferred to the ICU. E#13 stated that when Pt. #3 was transferred to the ICU, it was reported that there was some issues/delay starting the tube feeding. E#13 stated that it was reported that the supervisor and nurses couldn't locate a pump. E#13 stated that during rounds, the doctor (E#13 did not recall who) was upset why the feeding was not started. E#13 stated that E#13 went around the unit and found a feeding pump and the feeding was initiated right away. E#13 started that they would document the initiation of the tube feeding in the clinical record. E#13 believed that the feeding was started as soon as Pt. #3 arrived to the unit but wasn't entirely sure.

6. An interview was conducted with ICU Nurse (E#16) on 04/16/2025, at approximately 12:50 PM. E#16 stated that if there is an issue with administering a feeding with a pump, they can call the dietician and ask if they can give a feeding by bolus; and if yes, they would have to place an order for bolus feedings. E#16 stated that if an ICU patient is boarding in the ED for a while, sometimes they will send down a nurse to care for the patient or the ED staff will resume care until the patient is transferred to the unit. E#16 stated that if orders are placed for treatment whether the patient is still in the ED or up on the ICU, the orders should be executed right away.

7. An interview was conducted with the Quality Manager (E#24) on 04/17/2025 at approximately 12:15 PM. E#24 was reviewing the record of Pt. #10 and stated that E#24 could not find any documentation of why the feedings weren't administered on 04/12/2025 and 04/13/2025. E#24 stated that it should have been documented in the GI (gastrointestinal) tube section and/or on the Intake & Output flowsheets.



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B. Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) patients reviewed for intravenous (IV) assessments, the Hospital failed to ensure that IV assessments were completed and documented.

Findings include:

1. On 04/14/2025, the hospital's policy titled, "IV Peripheral Therapy Policy" (effective 02/2021) was reviewed and included, " .... Insertion site should be inspected prior to each use and at least once every shift .... Flush every 12 hours with 10 milliliter of 0.9% Normal Saline for 31 days old to adults .... Documentation: Discontinuation: date and time, condition of site ..."

2. On 04/15/2025 2:30 PM, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to 5th floor Medical-Surgical Telemetry Unit with a diagnosis of new onset diabetes with bilateral swollen legs. Pt.#1 had an IV placed on the left mid forearm on 2/12/2025 at 8:00 PM. Another IV was placed on 2/11/2025 at 2:43 PM on the right antecubital (inner front forearm). On 2/14/2025 at 2:35 PM, it was documented that both IVs were discontinued; however, the record lacked documentation of the condition of the IV sites at discontinuation as required.

3. On 4/15/2025 at approximately 10:12 AM, an interview was conducted with the Registered Nurse (E#2). E#2 stated that IV assessments are done every 12- hour shift, when medication is administered, and during endorsement. E#2 stated that IV sites must be checked for infiltration (leaking), swelling, or redness. E#2 stated that E#2 would discontinue the IV(s) and then document the removal in the record. E#2 stated that assessment of the IV site's condition should be documented at the time of discontinuation for every patient.