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Based on record review, policy and procedure review and interviews, the Hospital failed to ensure that for one patient, (Patient #1), out of a total of sample of eleven patients, documentation of the insertion of a nasogastric (NG) feeding tube (a flexible tube inserted through the nose and passed down into the stomach through which liquid food and medications can be administered) was not entered into the medical record according to Hospital Policy.


Findings include:


The Hospital Policy, titled "Nasogastric Tube Insertion and Removal", dated 9/2013, indicated that once the NG tube is inserted correct placement must be confirmed by x-ray before use (feeding, administration of medications). The Policy indicated that the date and time of the procedure must be entered into the Medical Record as well as the patient's tolerance to the procedure.


The Surveyor interviewed Family Member #1 at 8:00 A.M.on 6/2/14. Family Member #1 said that, while Patient (Pt.) #1 was at the Long Term Acute Care (LTAC) Facility, a NG feeding tube was inserted into Pt. #1 but the tube ended up in Pt. #1's right lung and not in his/her stomach which eventually caused a right-sided pneumothorax (collapsed lung). Pt. #1 was transferred to an Acute Care Hospital where he/she later passed away.


Review of Patient (Pt.) #1's Medical Record indicated that Pt. #1 was transferred from an Acute Care facility and admitted to the LTAC Facility at 5:20 P.M. on 3/8/14. The Medical Record indicated that Pt. #1 was admitted for multiple disciplinary interventions including pulmonary (pertaining to the lung) management of his/her newly inserted tracheostomy (a surgically created opening through the neck into the trachea (windpipe) to allow direct access to a breathing tube), nutritional management and physiatry (rehabilitation for patients who have been disabled as a result of a disease, condition, disorder, or injury). The Medical Record indicated that Pt. #1 had a NG tube in his/her left nares (nostril) upon admission to the LTAC.

Review of Pt. #1's Admission History and Physical, dated 3/8/14, indicated that Pt. #1 would be maintained on nothing by mouth and nutrition would be provided by a NG feeding tube.

The Physician Progress Note, dated 3/11/14, indicated that Pt. #1 had pulled his/her NG tube out.

The Surveyor interviewed Nurse Practitioner #2 (NP #2) at 7:11 A.M. on 6/4/14. NP #2 said that a new NG feeding tube was inserted by Nurse Practitioner #1 (NP #1), on 3/11/14. NP #2 said that the follow-up x-ray, to determine correct placement, indicated that the NG tube was in Pt. #1's right lung and was not in his/her stomach.

Review of Pt. #1's Medical Record did not indicate that a note regarding the insertion of the NG feeding tube by NP #1 was documented.

Review of NP #2's Progress Note, at 12:50 A.M. on 3/12/14 indicated that she tried to remove the NG tube but there was too much resistance so she stopped and called the on-call Physician. The Progress Note indicated that the on-call Physician said that, as long as Pt. #1's condition was stable, have the on-coming Physician assess Pt. #1 in the morning.

Review of NP #1's Progress Note, at 2:19 P.M. on 3/12/14, indicated the Physician removed the NG Tube and a follow-up x-ray indicated that Pt. #1 now had a right-sided pneumothorax.

The Surveyor interviewed NP #1 on 6/3/14 at 10:46 A.M. NP #1 said that she did not write a procedure note regarding the insertion of the NG feeding tube in Pt. #1's Medical Record.

Based on observation, record review and interviews, the Hospital failed to ensure that for one patient, (Patient #2), out of a total sample of eleven patients, the procedure regarding the administration of a medication (insulin) was followed according to hospital policy.


Findings include:


The Hospital Policy, titled "Insulin Administration", revised date 10/2013, indicated that insulin will be stored in the patient's cassette (separate secure drawer in automated medication dispensing cart) and the vial of insulin will be dated upon opening.


For Patient #2, observation of a medication pass, on 6/4/14 at 9:45 A.M. with Nurse #1, revealed that 2 open vials of insulin were on the shelf of a wall mounted cabinet in patient #2's room.


The Surveyor noted, with the Chief Clinical Officer in attendance, that neither of the two open vials of insulin were dated nor were they in the patient's cassette.


The Surveyor reviewed Pt. #2's Electronic Medication Administration Record (EMAR) with Nurse #1. The EMAR did not indicate that Pt. #2 was on insulin.

Based on observation, record review and interviews, the Hospital failed to ensure that for two patients, (Patient #10 & #11), out of a total sample of eleven patients, the documentation regarding the administration of blood was completed according to Hospital Policy.


Findings include:


The Hospital Policy, titled "Blood Product Administration", revised date 7/2013, indicated that the Blood Transfusion Record will contain: a) the date and time the transfusion was started, b) the time the transfusion was completed, c) the signature of the transfusionist (nurse starting transfusion) and signature of the nurse verifying the order, blood type and correct patient, d) pre-transfusion vital signs, 15 minute vital signs, hourly vital signs and one hour post transfusion vital signs and e) the amount of blood administered.


1) A review of the Blood Transfusion Record for Patient #10, dated 4/30/14 at 12:10 A.M., did not indicate the signature of the transfusionist.


A review of the Blood Transfusion Record for Patient #10, dated 4/30/14 at 3:30 A.M., did not indicate the volume of blood given or the one hour post transfusion vital signs.


A review of the Blood Transfusion Record for Patient #10, dated 5/10/14 at 8:35 P.M., did not indicate the signature of the nurse co-verifying the order, blood type and patient.


2) A review of the Blood Transfusion Record for Patient #11, dated 5/6/14 at 6:30 A.M., did not indicate the volume of blood administered.