Failure to Ensure Proper Labeling and Administration of Tube Feeding and GT Site Care
Summary
The facility failed to ensure proper labeling and administration of tube feeding (TF) for a resident, identified as Resident 55 (R55). On multiple occasions, the TF bag or container and water bag were not labeled with the resident's name, TF rate, date/time, and nurse's initials as ordered by the physician. This was confirmed by a Registered Nurse (RN) who acknowledged the risk of misidentification due to the lack of labeling. Additionally, there was a discrepancy between the TF rate documented in the Medication Administration Record (MAR) and the actual rate being administered, which was not updated in the electronic record as per the new physician's order. The Director of Nursing (DON) confirmed that the staff failed to verify, transcribe, and update the MAR to match the actual TF rate delivered by the pump, leading to confusion and improper administration of the TF rate for R55. The Registered Dietitian (RD) also confirmed that the new order was not transcribed and the MAR was not updated accordingly. The facility policy required that all aspects of the resident's care be provided in accordance with physician orders, which was not followed in this case. Furthermore, the facility failed to obtain, transcribe, and implement care orders for the gastrostomy tube (GT) site and dressing change for R55. The GT site dressing was observed to be dated 04/30, indicating that it had not been changed as scheduled. The RN confirmed that the GT site should have been cleansed and the dressing changed daily at night, but this was not done. The wound nurse practitioner (WNP) and the Assistant Director of Nursing (ADON) indicated that both the Licensed Nurses and the Wound Care Team were responsible for the GT site care and management. However, the medical record lacked documented evidence of care orders for the GT site, and the dressing change was not implemented as required. The facility's policies on Physician Orders and Enteral Feeding Tube Care were not adhered to, resulting in the failure to provide adequate care and services to R55. The policies required that physician orders be documented and transcribed accurately, and that the GT site be monitored and the dressing changed to prevent infection. The DON acknowledged that the staff skipped the process, leading to confusion and non-compliance with the facility's policies. The failure to follow these policies could have jeopardized the resident's health and well-being.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with multiple complex conditions, including dementia, dysphagia, and dependence on G-tube feeding, had physician orders for continuous tube feeding, scheduled water flushes, and daily cleansing of the G-tube site with application of a sponge dressing. During observation, an LPN found the G-tube site without the ordered dressing and cleaned brown/red dried drainage from the insertion area, acknowledging that a dressing should have been in place. The DON later reported there was no formal facility policy or procedure for G-tube care and maintenance, even though additional residents also had G-tubes.
A resident with multiple serious conditions, including anoxic brain damage, respiratory failure, dysphagia, and gastrostomy status, had physician orders for Jevity 1.5 bolus tube feedings every four hours and PEG flushes with 60 mL water before and after each feeding and every four hours. EMR and MAR review showed that on one day the resident did not receive the ordered bolus feedings or PEG flushes at two scheduled administration times, contrary to physician orders, the facility’s medication administration policy, and the resident’s right to adequate and appropriate medical and nursing care.
A resident with severe cognitive impairment and a PEG tube did not receive the prescribed amount of enteral nutrition when the tube feeding pump repeatedly indicated a clog and was not infusing. The LPN on duty had not yet checked on the resident and was unaware of the issue, resulting in the resident missing the ordered nutrition.
A resident with multiple medical conditions and a PEG tube developed mold within the feeding tube due to the facility's failure to provide proper routine care and monitoring as ordered. Staff did not recognize or report the discoloration in the tube, and the issue was only addressed after the resident was sent to the hospital for evaluation and tube replacement.
A resident with multiple medical conditions, including malnutrition, was readmitted from the hospital with an order for Nutren 2.0 tube feeding. The facility did not enter the tube feeding order into the medical record or provide the prescribed nutrition, as the ordered formula was not available and no alternative was used, despite facility policy allowing for basic formulary products until specialized products could be delivered.
A resident with a PEG tube and multiple medical conditions was admitted with a physician's order for nocturnal Jevity 1.5 tube feeding. Due to the facility being out of Jevity 1.5, an LPN substituted Jevity 1.2 two days after admission, resulting in the resident not receiving the ordered formula for two nights.
Failure to Provide Ordered G-Tube Care and Dressing
Penalty
Summary
The deficiency involves the facility’s failure to provide gastrostomy tube (G-tube) care and maintenance as ordered for a resident who was fully dependent on tube feeding. The resident had multiple diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, a G-tube, and hypertension, and was documented on the MDS as being in a persistent vegetative state, severely cognitively impaired, unable to make needs known, dependent for all ADLs, incontinent, and receiving all nutrition via feeding tube. The care plan identified potential for altered nutrition/hydration, with the resident ordered NPO and dependent on tube feeding and flushes, and included interventions such as administering medications as ordered, elevating the head of bed, and evaluating tube feed tolerance. Physician orders specified continuous tube feeding with Glucerna 1.2 via G-tube for up to 20 hours per day with scheduled water flushes, and a treatment order to cleanse the area around the G-tube with soap and water and apply a new sponge dressing daily and as needed. During an observation, an LPN entered the resident’s room and exposed the G-tube site, at which time no dressing (sponge) was in place despite the physician’s order for a daily dressing. The LPN cleansed a small amount of brown/red dried drainage from the G-tube insertion site and confirmed that a dressing should have been applied. In an interview, the DON stated that the facility did not have a policy or procedure in place regarding the provision of G-tube care and maintenance, and that the procedure was considered a standard of practice task. The facility also identified two additional residents with G-tubes, indicating that more than one resident required such care, but the cited deficiency specifically involved the failure to follow ordered G-tube care for this resident.
Failure to Provide Ordered Tube Feeding and PEG Flushes
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered enteral nutrition and PEG tube care for a resident with complex medical conditions. The resident was admitted with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, history of sudden cardiac arrest, CHF, liver disease, and cerebral infarction. A recent MDS assessment showed the resident was unable to complete a BIMS cognitive assessment and required total assistance for hygiene, dressing, repositioning, transferring, and locomotion via wheelchair. Review of the EMR and MAR showed that the resident had a physician order, dated 10/24/25, for Jevity 1.5, 237 mL bolus tube feeding every four hours, and an order to flush the PEG tube with 60 mL of water before and after each bolus feeding and every four hours. On 02/22/26, the MAR documented that the resident did not receive the ordered Jevity 1.5 bolus feedings at 10:00 a.m. and 2:00 p.m., nor the required PEG tube flushes at 10:00 a.m. and 2:00 p.m. This failure occurred despite facility documentation stating that medications are to be administered in accordance with professional standards of practice and the resident agreement stating the right to adequate and appropriate medical and nursing care. The deficiency was investigated under Complaint Number 2793023.
Failure to Provide Ordered Tube Feeding Due to Unresolved Pump Clog
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dysphagia following cerebral infarction, hemiplegia, hemiparesis, and aphasia did not receive the ordered amount of tube feeding. The resident was dependent for all activities of daily living and had a physician order for continuous enteral nutrition at 75 cc per hour, with specific instructions for formula type and flushes. Observations revealed that the resident's tube feeding pump was repeatedly beeping and displaying a 'clog in line downstream' error, with 370 ml remaining in a 1000 ml container that had been initiated earlier that day. The tube feeding was not infusing as ordered. Further review and interviews confirmed that the tube feeding should have been completed by early afternoon, but the resident had not received the full prescribed amount. The LPN on duty at the time had not yet checked on the resident and was unaware that the tube feeding had not been infusing. This resulted in the resident not receiving the ordered nutrition, as confirmed by both observation and staff interview.
Failure to Prevent Mold Formation in Feeding Tube
Penalty
Summary
The facility failed to provide proper care for a resident's feeding tube, resulting in mold formation within the tube. The resident, who had multiple complex medical diagnoses including cerebral infarction, diabetes, hemiplegia, anoxic brain damage, and dysphagia, was dependent on staff for all activities of daily living and had a PEG tube for nutrition and hydration. Physician orders required regular hydration flushes every four hours, daily cleansing of the PEG tube site, and routine tube feedings. Despite these orders, the internal tubing developed brownish discoloration and mold, which was not identified or reported by staff in a timely manner. Staff interviews revealed that certified nursing assistants had noticed the discoloration but did not recognize it as mold, and licensed nurses did not observe or report the issue during routine care. The facility's policy required licensed nurses to provide routine care to maintain tube patency and skin integrity, but this was not followed, as evidenced by the presence of mold in the tube. The resident was eventually sent to the hospital for evaluation and replacement of the PEG tube after the mold was discovered.
Failure to Implement Tube Feeding Orders Upon Readmission
Penalty
Summary
The facility failed to implement tube feeding orders for a resident upon readmission from the hospital. The resident, who had diagnoses including COPD, major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition, was readmitted with a hospital order for Nutren 2.0 tube feeding at a specified rate. However, there was no corresponding physician order for tube feeding entered into the resident's medical record upon return, and the Medication Administration Record did not document any tube feeding administration during the relevant period. The care plan identified the resident as being at moderate nutritional risk and included interventions to provide enteral feedings as ordered. Despite this, the Director of Nursing confirmed that tube feeding was not provided from the time of readmission because the facility did not have the prescribed formula available. Facility policy indicated that staff could use products from a basic formulary until specialized products could be delivered, but this was not done, resulting in the resident not receiving the ordered nutritional support.
Failure to Provide Ordered Enteral Nutrition Due to Formula Substitution
Penalty
Summary
A review of the medical record and staff interviews revealed that a resident with diagnoses including malignant neoplasm of the lung, malnutrition, depression, and a history of falls was admitted with orders for nocturnal enteral feeding using Jevity 1.5 at 70 mL/hr via PEG tube. The care plan specified that tube feeding should be administered as ordered due to the resident's inability to consume adequate nutrition orally. The resident was cognitively intact and required varying levels of assistance for activities of daily living, and was coded for a feeding tube on the Minimum Data Set. Despite the physician's order for Jevity 1.5, the facility did not have this formula available upon admission. Instead, an LPN reported that Jevity 1.2 was started two days after admission, and the resident went without the ordered Jevity 1.5 for two nights. This deviation from the physician's order resulted in the resident not receiving the prescribed enteral nutrition as required.
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