Failure to Hold Tube Feeding Leads to Resident Hospitalization
Summary
The facility failed to follow a physician's order to hold a tube feeding for a resident after an episode of vomiting, leading to severe health complications. The resident, who had a history of stroke, dysphagia, and was dependent on a feeding tube, experienced vomiting after a bolus tube feeding was administered. Despite a subsequent order from a Nurse Practitioner to hold the tube feeding due to intolerance, the order was not correctly entered into the electronic Medication Administration Record (MAR), resulting in the feeding continuing overnight. The resident was found the next morning with symptoms of respiratory distress, including coughing, struggling to breathe, and emesis of tube feeding from the nose and mouth. The resident's condition was critical, with low oxygen saturation and elevated heart rate, necessitating emergency medical intervention and hospitalization. The failure to hold the tube feeding as ordered and to maintain the resident's head of the bed elevated contributed to the resident's aspiration and subsequent hospitalization. Interviews with staff revealed that the order to hold the tube feeding was not communicated effectively, and the electronic MAR did not reflect the hold order, leading to the continuation of the feeding. The incident highlighted a breakdown in communication and procedural adherence, resulting in significant harm to the resident.
Removal Plan
- The Nurse Practitioner ordered a diagnostic imaging for the Kidneys, Ureters and Bladder, a complete blood count, basic metabolic panel, Zofran 4 mg every 6 hours as needed for nausea and to hold tube feedings.
- The Assistant Director of Nursing reviewed the electronic medical record and determined that the tube feeding order was never placed on hold and Resident #98 received enteral tube feeding.
- Root cause was discussed by the Interdisciplinary team and it was determined that an additional order to hold the tube feeding was entered into the Electronic Medical Record but the actual tube feeding order was not placed on hold.
- The Assistant Director of Nursing reviewed the electronic medical records for all other residents that had received enteral feeding to ensure the tube feeding orders were correct and there were no missed hold orders and that each resident had an order to maintain the head of the bed at 30-40 degrees during feeding and for 30 minutes after, if tolerated.
- The Assistant Director of Nursing provided education to the nurses on appropriately placing an order on hold instead of entering an additional hold order.
- The nurse who failed to enter the order correctly received one on one education on appropriately placing an order on hold instead of entering an additional hold order by the Assistant Director of Nursing.
- Unit Managers, the Wound Care Nurse and the Minimum Data Nurse were educated during the Interdisciplinary Team meeting by the Assistant Director of Nursing.
- The Assistant Director of Nursing contacted all nurses and certified nursing assistants and provided education on ensuring residents with enteral tube feeding are kept at a 30-40-degree angle when in bed. 100% education was completed via telephone.
- The Director of Nursing or designee will review all new orders to ensure any orders to hold tube feedings, medications or treatments were applied to the actual tube feeding, medication or treatment order instead of only entering an additional hold order.
- Weekend orders will be reviewed during the Clinical Morning Meeting.
- The facility determined the need to take the plan of correction to the Quality Assurance Performance Improvement Committee.
- A meeting was held with the Medical Director and the Quality Assurance Performance Improvement committee to review the plan of correction and the monitoring plan.
- The facility conducts concierge rounds for all residents. Residents with enteral feeding are assigned the Minimum Data Set nurse.
- The concierge document includes resident bed positioning and are discussed in the administrative meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a gastrostomy tube and diagnoses including adult failure to thrive and malnutrition had physician orders for continuous Isosource 1.5 tube feeding and scheduled free water flushes. Surveyors observed that the resident’s tube feeding bottle and water flush bag were not dated on multiple occasions, and both the DON and an LPN confirmed the absence of dates on these supplies. Facility leadership acknowledged that appropriate care and services were not ensured for this resident receiving enteral feeding.
A resident with paraplegia and dysphagia, who received medications via an enteral tube, had a physician order requiring tube placement to be checked by auscultation before medication administration. An RN administered water and liquid hydroxyzine HCl through the tube and flushed it without verifying tube placement. The facility’s policy referenced following professional standards and verifying tube placement per protocol, but the RN reported not knowing the policy on checking placement or residual, and the CNO stated the G-tube policy did not require checking placement or residual before medications or feedings, relying only on x-ray at insertion. This resulted in a deficiency related to inadequate care and treatment for enteral tube use.
A resident with cerebral palsy, chronic respiratory failure, and a gastrostomy had physician orders for continuous enteral nutrition at 55 cc/hr and a hydration flush at 70 cc/hr. Facility policy required verification of enteral feeding rates against the orders before administration. On multiple observations, the resident’s feeding pump was set to 50 cc/hr and the hydration flush to 80 cc/hr. An RN confirmed these incorrect settings and acknowledged they did not follow the physician’s orders.
A deficiency was cited after surveyors found that multiple residents receiving enteral nutrition did not receive care consistent with facility policy, physician orders, or manufacturer guidance. Tube feeding bags were often hung without dates or times, tubing connectors were left uncapped between uses, and pumps and IV poles were visibly soiled with dried formula. A resident with a G-tube and severe cognitive impairment twice developed abdominal wall cellulitis identified by an adult day care center, with no prior documentation of infection signs by facility staff despite orders to monitor the site each shift. Other residents had medications administered via PEG or G-tubes without verification of tube placement, feedings started late or allowed to run past ordered stop times, and feeding systems spiked and primed hours before use with open, uncovered connectors. Staff interviews confirmed that protective caps were not supplied, that they were behind on tasks, and that they were aware these practices could introduce contamination, leading to the cited deficiency in enteral feeding management.
A resident with dysphagia and malnutrition, dependent on tube feeding, was repeatedly observed receiving Jevity 1.5 at 80 mL/hr while lying flat or with the head of bed below the ordered 30-degree elevation. Open Jevity containers, including one from the prior day and another undated, were left partially full on the tray table, and the feeding bag in use was not labeled or dated over multiple observations. An LPN acknowledged the resident was positioned "way too flat" and that enteral formulas should be dated and discarded appropriately, but no further assessment was performed. These actions and omissions conflicted with the resident’s orders, care plan, and the facility’s enteral feeding policy requiring semi-Fowler’s positioning and proper formula dating.
The facility failed to follow physician orders and ensure complete documentation for tube feeding care for two residents. One resident with neurological impairments and dysphagia, dependent on G-tube feeding and NPO, had multiple undocumented enteral feedings, water flushes, residual checks, and pre- and post-medication water administrations across several shifts, with staff acknowledging awareness of missed feedings and incomplete audits. Another resident dependent on tube feeding for hydration had no ordered water flush amount on the MAR for medication administration; during an observed med pass, an RN relied on the DON’s statement of a "standard" 60 cc flush before and after medications, despite no written order and no clear facility policy guiding medication administration via feeding tube.
Undated Enteral Feeding and Water Flush Supplies for Tube-Fed Resident
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via gastrostomy tube did not receive appropriate care and services related to the management of tube feeding and water flush supplies. The resident, admitted with diagnoses including encounter for attention to gastrostomy, adult failure to thrive, and malnutrition, had care plan and physician orders directing provision of tube feeding with Isosource 1.5 at 60 ml/hr for 22 hours daily and free water flushes of 150 ml every four hours, six times a day. During observations on two separate days, surveyors noted that the resident’s Isosource 1.5 bottle and 1000 ml water flush bag were not dated, and on a subsequent observation the water flush bag remained undated. The DON and an LPN confirmed that the tube feed and water flush bag lacked required dating, and facility leadership acknowledged that the facility failed to ensure appropriate care and services for this resident receiving enteral feeding.
Failure to Verify Enteral Tube Placement Before Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s care and treatment of a resident with an enteral feeding tube when staff failed to verify tube placement prior to administering medication. The facility’s “Medication Administration Enteral Access Device” policy, released 9/16/25, directed staff to follow general professional standards for safe administration of medications and to verify tube placement per facility protocol. The resident, admitted with diagnoses including paraplegia and dysphagia, had a physician’s order dated 1/21/26 specifying that medications may be crushed or given in liquid form via the enteral tube and that tube placement must be checked via auscultation before medication administration. On 4/1/26 at 9:00 AM, an RN administered 30 mL of water through the resident’s enteral tube, followed by 20 mL of liquid hydroxyzine HCl, and then flushed the tube with 30 mL of water, without verifying tube placement beforehand. When interviewed shortly afterward, the RN stated she was unsure of the facility’s policy on checking tube placement and residual prior to administering medications, and the CNO reported that the facility’s G-tube policy did not require checking residual or placement before feedings or medication administration, indicating placement was only checked by x-ray at the time of insertion. This failure to verify tube placement before medication administration was determined to be a lack of adequate care and treatment for the resident reviewed for enteral tube use, creating the potential for harm if complications developed from improper medication administration via the enteral access device.
Incorrect Enteral Feeding and Hydration Rates Not Following Physician Orders
Penalty
Summary
The facility failed to provide enteral nutrition and hydration in accordance with physician orders for one resident receiving tube feeding. Facility policy on enteral tube feeding via continuous pump required staff to check the enteral nutrition label against the order before administration, including verifying the rate of administration in mL/hour. The resident, admitted with diagnoses including cerebral palsy, chronic respiratory failure, and a gastrostomy, had physician orders dated 12/31/25 for continuous pump feeding of Peptamen AF at 55 cc/hr and a hydration flush at 70 cc/hr over 24 hours. On multiple observations on 3/23/26 at 10:30 a.m., 12:30 p.m., and 1:25 p.m., the resident was observed in bed receiving enteral feeding via g-tube with the feeding pump set at 50 cc/hr and the hydration flush set at 80 cc/hr, which did not match the physician’s orders. During an interview at 1:30 p.m. the same day, an RN confirmed that the feeding rate and hydration flush settings were 50 cc/hr and 80 cc/hr, respectively, and acknowledged that these settings were not in accordance with the resident’s physician orders and should have been set per those orders.
Failure to Maintain Safe, Timely, and Sanitary Enteral Feeding Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent complications related to enteral nutrition for six residents with feeding tubes. Surveyors found that tube feeding systems were frequently hung without being dated or timed, and tubing connector tips were left uncapped between uses, despite facility policy and manufacturer guidance requiring protection of components that contact formula. Multiple residents had feeding containers spiked and primed but not infusing, with the open ends of tubing left exposed and no protective caps available. Staff interviews confirmed that caps were not provided by the facility, and nurses acknowledged that uncovered connectors could introduce germs and place residents at risk for infection. For one resident with a gastrostomy tube and severe cognitive impairment, the care plan and orders required monitoring the G-tube site for infection every shift and checking tube placement and gastric residuals. The resident was sent twice from an adult day care center to the Emergency Department and diagnosed with abdominal wall cellulitis on both occasions, after the day care staff identified abnormal G-tube findings, including leakage and inability to flush the tube. The facility’s clinical record contained no documentation that staff had identified or recorded signs or symptoms of infection before the resident left for day care on either occasion, and the Physician Assistant reported she had not been notified of excessive leakage that could contribute to recurrent cellulitis. During observation, this resident’s G-tube site was reddened with yellowish-green drainage, the feeding container had been spiked the previous day and was being reused, the connector was left uncovered, and the pump and IV pole had dried formula residue. Other residents with PEG or G-tubes also experienced deficiencies in enteral feeding management. Several residents had tube feedings hanging and infusing without dates or times on the bags, and tubing sets were observed primed and hanging with open, uncapped ends. One resident received medications via PEG tube without the nurse checking tube placement beforehand, despite a care plan intervention to check placement and gastric contents per protocol. Another resident’s feeding was labeled to start later in the day but was already spiked and primed hours in advance, with the connector left uncovered and the pump and IV pole soiled with dried feeding residue. For a resident ordered to receive tube feeding from late afternoon to early morning, the feeding was started approximately two hours late and then observed still infusing well past the ordered stop time; the resident was later found in bed with a large amount of emesis on the gown and linens, and the LPN stated she had been running behind and had not turned off the feeding. Throughout these observations, the DON, PA, RD, and product representative all confirmed that connectors should be covered, feedings should follow ordered schedules, and systems should not remain hanging beyond recommended timeframes, but the facility’s practices did not align with these expectations. Across multiple days of observation, the surveyors repeatedly noted that enteral feeding pumps and IV poles for several residents were coated with dried feeding residue on the exterior surfaces, along the poles, and at the bases, indicating that equipment used for tube feeding was not maintained in a clean and sanitary condition. Facility policies on enteral nutrition and G-tube site care required staff to monitor for signs of infection, maintain cleanliness of the tube site, assess for redness, swelling, pain, or drainage, and report signs of infection to a supervisor and physician. The policies also emphasized confirming tube placement prior to initiating feedings to reduce aspiration risk and recognizing complications such as aspiration, tube misplacement, skin breakdown, and gastrointestinal symptoms. Despite these written policies and the manufacturer’s guidance on closed versus open systems, hang times, labeling, and handling to prevent contamination, staff actions and inactions—including failure to document and report abnormal G-tube findings, failure to verify tube placement before medication administration, failure to adhere to ordered feeding schedules, and failure to keep connectors capped and equipment clean—led to the cited deficiency for all six residents receiving enteral nutrition.
Failure to Maintain Safe Positioning and Handling of Enteral Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate care and monitoring for a resident receiving enteral nutrition. The resident had a history of dysphagia following a cerebral infarction and moderate protein-calorie malnutrition, and was dependent on tube feeding and water flushes. Physician orders and the care plan required Jevity 1.5 at 80 mL/hr at bedtime and elevation of the head of bed to at least 30 degrees during feeding. On multiple observations, the resident was found lying flat or with the head of bed not elevated to 30 degrees while the tube feeding was running. During one observation, the assigned LPN acknowledged that the resident was “way too flat” and raised the head of bed to 45 degrees but did not further assess the resident. The facility also failed to ensure proper handling and labeling of enteral feeding formula. Surveyors observed two opened bottles of Jevity on the resident’s tray table, one dated from the previous day and one not dated, both partially full. The running formula bag was not labeled or dated to indicate when the formula was opened or when the feeding was started, and this lack of labeling persisted across several observations on consecutive days. The LPN caring for the resident stated that the open Jevity containers should have been discarded and that nurses were supposed to date enteral feeding formulas with the date and time when opened to ensure the formula was safe and not spoiled. These practices were inconsistent with the facility’s enteral feeding policy, which required residents to be in semi-Fowler’s position (30–45 degrees) during administration and for 30 minutes to one hour after to prevent aspiration.
Failure to Follow Tube Feeding Orders and Document Enteral Nutrition and Flushes
Penalty
Summary
The deficiency involves the facility’s failure to provide tube feeding care and related water flushes and residual checks according to physician orders and to ensure complete documentation for residents receiving enteral nutrition. For one resident with moderately impaired cognition, traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dysphagia requiring G-tube feeding and NPO status, the care plan directed enteral nutrition as ordered. The January and February MARs contained orders for Fibersource HN 375 ml four times daily as a nutritional supplement, 150 ml water flushes with each feeding, residual checks of 5–20 ml prior to every medication pass or feeding each shift, and 60 ml water before and after medications every shift. Surveyors found multiple instances across January and February where feedings, water flushes, residual checks, and pre- and post-medication water administrations were not documented as completed. The clinical record review showed specific missed documentation dates and times for this resident’s tube feedings and associated water flushes, including several lunch and hour-of-sleep doses in January and mid-afternoon and evening doses in February. Residual checks and 60 ml water flushes before and after medications were also not documented on multiple shifts. The Medical Director acknowledged awareness that the resident missed a few feedings and confirmed the expectation that staff follow provider orders as written. An LPN and the MDS Coordinator both reported knowing that the resident had missed some feedings, and the MDS Coordinator stated that if it is not documented, it is not done and that audits were not completed, confirming gaps in both performance and documentation of ordered enteral nutrition and hydration. For a second resident with intact cognition and diagnoses including stroke, heart failure, hypertension, diabetes mellitus, and dependence on tube feeding for nutrition and hydration, the care plan directed flushing the feeding tube as ordered. However, the March MAR did not specify the amount of water to flush the feeding tube before and after medication administration. During an observed medication pass, an RN asked the DON about the required flush amount; the DON left the room and returned stating that 60 cc of water should be used before and after medications, describing this as the standard amount, despite no corresponding order on the MAR. The RN and DON then administered 60 cc water flushes based on this verbal direction. The ADON confirmed she did not see an order for the water flush amount, and the DON acknowledged the lack of a policy directing staff on how to administer medications via tube feeding, while the existing enteral feeding policy only addressed verifying physician orders for formula, rate, and frequency.
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