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Based upon review of medical records, staff interviews, policies and procedures, it was determined that nursing service had failed to provide nursing care to meet all of the patient's needs for two (2) of two (2) patients (#'s 1 and 2).


Findings were:

Review of patient #1's medical record revealed the patient had a PEG (percutaneous endoscopic gastrostomy ) tube and received tube feedings and medications through the tube. The medical record lacked documented evidence that the patient's PEG tube was checked for residual every four hours on the following days; hospital day #2 through #5, #7, #9 through #12, #14 through #19, #21, #24 through #28, #30, #33 through #35, #37, #39 through #41, #43 through #47, and #52. In addition, from hospital days #2 through 55, documentation revealed the patient's PEG tube was flushed 246 out of a possible 312 times.

Review of patient #2's medical record revealed the patient had a PEG tube and had received tube feedings and medications through the tube. From hospital days #7 through 14, documentation revealed the PEG tube was flushed 22 of a possible 42 times.

Staff interviews with the registered nurse and interim case manager on 4/7/11 at 11:25 a.m. and 3:30 p.m., respectively, confirmed that the patients PEG tube was to be checked for residuals and flushed every four hours.

Review of the facility's policy entitled, "Gastric/Duodenal Tube", revised 1/1/11, revealed residual checks were to be performed every 4 hours on all types of gastric feeding tubes.




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