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Based on observation, interview and record review, the facility failed to provide one patient (P-1) of 2 patients reviewed for dependency on tube feedings with comprehensive nutritional support resulting in P-1 not receiving adequate nutritional support and less than optimal outcomes for the patient. Findings include:

On 04/30/25 at approximately 1600 P-1 was observed and interviewed in her room. Patient's GJ tube (Gastrojejunostomy tube- is a soft, narrow tube that enters the stomach in the upper part of the abdomen and is threaded into the small intestine) was observed connected to the bottle with tube feeding formula and was infusing at 10 ml/h (milliliters in hour). Patient stated that on her admission to the facility she experienced pain with tube feeding and at the site of its insertion. She added that the balloon that holds tube in place was partially visible when she was admitted and at some point during her stay here it "popped out" and was sitting on her skin. She said that bile was leaking all over her stomach area and she experienced great deal of pain and discomfort, not to mention that her medications and feeding was paused till GI (Gastroenterology) service "fixed" the balloon issue. P-1 added that all this time since admission she was unable to tolerate feeding infusion higher than 10 ml/h no matter what formula was running. "I am in pain when it runs higher than 10, and I can feel the same discomfort and nausea when nurses give me meds and flushes", she said. She stated that she feels dizzy, weak and lightheaded.

P-1's medical record was reviewed on 04/30/25 and revealed:
General medicine physician note dated 4/24/25 0815: "Patient states that her pain started one day prior to presentation, she also noted that the site of the tube is more red than usual. Pain at the GJ tube site worsens with moving the tube or administering any tube feeds or medications through her tube, this patient has not been able to get any feeds or take any of her medications since yesterday which prompted her to present to emergency department. Appropriate GJ tube positioning was confirmed on Xray (PEGogram)".

Gastroenterology provider note dated 4/24/25 1217 indicated: "Ok for clears. Ok to use J portion for feeds. Would benefit from an EGD as outpatient to evaluate if she continues to have epigastric pain".

Weight on admission (04/23/25 at 2031) was recorded as 61.2 kg, method- estimated/emergent, height 5'8" (172.7 cm).

Registered dietitian (RD) note dated 4/25/25 1046 revealed: "Nutrition interventions/recommendations: Jevity 1.5 (nutritional tube feeding formula) with fiber initiate at 10 ml/h, advance as tolerated to goal of 50 ml/h x 24 hrs via J tube to provide: 1800 kcal/day, 77 gram/day protein, 259 gram/day (10.8 g/hr) carbohydrates, 25 gram fiber, 912 ml/day free water. Flushes 30 ml every 4 hrs for patency. Home TF (tube feeding) regimen: Jevity 1.5 at 50 ml/hr. Malnutrition criteria met? No".

There was a provider order dated 04/25/25 1102: Tube feed Jevity 1.5, route PGJ, continuous, goal as tolerated 50 ml/hr. Discontinued 04/29/25 1030.

Wound care consult note dated 04/28/25 0856 revealed: consulted for help with G tube that is leaking enteric contents and causing the patient pain.

Gastroenterology consulting physician note dated 04/29/25 1648 had the following documented: pain and redness at the site of PEG J probably related to skin irritation from bile leakage from displaced and deflated ballon. Status post repositioning. Upon evaluation erythema was noted around the PEG site and the balloon was noted to be outside the ostomy. The ballon was completely deflated and repositioned with subsequent inflation of the ballon with 10 ml of sterile saline. Recommendations: hold tube feeds for another 5-6 hours and then restart with minimal manipulation of the tube. If symptoms of pain do not improve, we will consider scheduling patient for an EGD (esophagogastroduodenoscopy or upper endoscopy that examines esophagus, stomach and duodenum with scope).

Registered dietitian (RD) note dated 4/30/25 1354 revealed: "Malnutrition criteria met? Yes. Malnutrition diagnosis: moderate protein-calorie malnutrition. Acute illness of injury: enteral access complication. Subcutaneous body fat loss acute illness: mild. Muscle mass loss acute illness: mild. Energy intake: less than 75% for greater than 7 days (patient states she has not had tube feeding at goal for > 7 days. Weight loss: patient states she has lost weight, unsure of amount, bed scale on admission possibly discrepancies [sic]. Intervention: Trial GI product Peptamen 1.5, follow up tolerance".
There was a provider order dated 04/30/25 1400: Tube feed Peptamen 1.5, route PGJ, continuous, start at 10 ml/h via pump to J port, increase rate by 10 ml every 12 hours or per patient preference, eventual goal rate 50 ml/hr x 24 hrs/day.

There was no record of the RD follow up notes regarding P-1 tolerance of the ordered tube feeding formula, rate or any complications between 04/25/25 and 04/30/25.

Further record review revealed that P-1 received total of 420 ml of intermittent tube feeding during her admission from 04/23/25 until 04/30/25 at approximately 1600. As per RD recommendations the goal for the patient was "50 ml/h x 24 hours via J tube to provide: 1800 kcal/day". That would be a goal of 1200 ml a day and a total of 7200 ml for 6 days. No orders for additional nutritional supplements were identified during record review. Also, there was no accurate (only estimated) weight recording for P-1 on admission and throughout patient's stay, therefore, no accurate determination could be made if patient lost weight and how much.

On 05/01/25 at 1040 P-1 internal medicine physician, Staff DD, was interviewed. During the interview he stated that he was communicating the plan of care for P-1 with the patient and her mother/guardian. He added that appropriate consultations were placed on admission, including GI and registered dietitian. When asked if he knew how much total feeding patient received during her stay in the facility, Staff DD said that he was not aware of the total amount. He stated that the treating team's goal was to advance patient's feeding rate gradually over time and see if she would tolerate that. When queried what the current rate of the patient's tube feed infusion was, he referred to his colleague, an internal medicine physician who took over the case, Staff CC. She stated that as of today, 05/01/25, the rate was still at 10 ml/h.

Facility policy "Protocol Medical Nutrition Therapy: Nutrition Orders Protocol, effective 07/21/24, was reviewed on 05/01/25 and revealed:
"4.2. Protocolized Other Orders:
4.2.1. Enteral Feeding/ Tube Feeding Orders: Order, Modify, Discontinue.
4.2.2. Water flushes: Order, Modify, Discontinue.
4.2.3. Nutrition Supplements: Order, Modify, Discontinue.
4.2.5. Weigh Patient: Order, Modify Discontinue
4.2.5.1. Indicate equipment to be used (bed, floor, or chair scale)
6. Inclusion Criteria 6.2. Criteria
6.2.3. Presence of one or more of the following nutrition risk factors:
6.2.2. All bedded patients, inpatient and observation status.
Malnutrition Screening Tool (MST) score of 2 or greater
Weight loss
Decreased nutritional intake or decreased appetite
Muscle wasting or fat wasting
Dysphagia
Parenteral or enteral nutrition
Nutritional Therapy Protocol- Tube Feeding Adjustment Guidelines.
Based on nutrition assessment, when nutrition therapy protocol is ordered- the RDN may adjust tube feeding and additive according to the following guidelines.
Tube feeding product selection. Clinical scenario indicates patient needs. Dietitian will select the following formula type (genetic name). Comments: See Enteral and Oral Supplement Formulary, document order, include follow-up date for monitoring (tolerance and complications).
Tube feeding- rate and or product change. If GI intolerance persists- consider product change.
Weigh patient. If patient accurate weight needed for provision of care, then weigh patient now and every day, indicate equipment to be used (bed, floor or chair scale)."

Based on observation, interview, and record review, the facility failed to ensure staff followed procedures for transmission-based precautions (TBP) for one patient (P-1) out of one reviewed for infection control practices, resulting in possible spread of infection to all patients on the unit. Findings include:

A review of P-1's medical record revealed that they were admitted to the facility on 4/23/25 with a chief complaint of GJ tube (feeding tube) site pain. Patient had a history of autism spectrum disorder, chronic suprapubic (urinary) catheter, gastroesophageal reflux, gastroparesis, inflammatory bowel diseases, moderate protein-calorie malnutrition, psychogenic nonepileptic seizures, seizure-like activity, POTS (postural orthostatic tachycardia syndrome), Conversion disorder (a psychological condition that causes symptoms that appear to be neurological, such as paralysis, speech impairment, or tremors, but with no obvious or known organic causes), and depression.

On 4/30/25 at 1545, Nursing Assistant (NA), Staff R, and NA Staff Q were observed in P-1's room providing care without wearing gowns.

On 4/30/25 at 1600, P-1 was observed in their room. A Contact Precaution sign was observed on P-1's door. P-1 explained that they are on contact precautions for an infection.

On 4/30/25 at 1601, During an interview, Registered Nurse (RN), Staff P, was asked if wearing PPE was required to enter P1's room. Staff P explained that PPE is only required when providing care.

On 4/30/25 at 1602, Staff R was observed in P-1's room checking vital signs on the bedside monitor without wearing a gown. Staff R was observed to remove a pen and paper from their pocket while wearing gloves and then place the pen and paper back into their pocket. Staff R then removed one glove and repositioned P-1's over-bed table with their bare hand. Staff R then exited the room. No hand hygiene was observed prior to exiting the room.

On 4/30/25 at 1645, during an interview, the unit Clinical Nurse Manager, Staff N, explained that all staff and visitors should wear appropriate PPE when entering the room of a patient on contact precautions.

A review of the facility's policy titled "Isolation - Transmission Based Precautions" effective 7/21/2024 revealed the following: "1. Purpose. To outline the process for the use of transmission-based precautions, also known as isolation precautions and proper use of personal protective equipment (PPE). Transmission-based precautions are infection control and prevention measures used in addition to standard precautions to protect against exposure to a suspected or identified pathogen. These precautions are specific and based on the way the pathogen is transmitted. The guidelines follow the recommendations from the Centers for Disease Control and Prevention (CDC). Contact Precautions 6.1.1. Contact Precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact (e.g., multi-drug resistant organisms, lice). PPE is to be worn by all team members entering the patient room. 6.1.7. Hand Hygiene must be performed prior to donning PPE and upon entering the patient's room ...6.1.8. Gloves and gowns must be worn at all times for Contact Precautions."