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 g-tube, dysphagia, and malnutrition had an enteral feeding order that omitted the formula strength and the administration method. The chart showed the resident was receiving Isosource 1.5 cal bolus feedings, but the active order only stated enteral feed via g-tube. The MDS Coordinator, LVN, and DON all acknowledged the order was incomplete, and the facility policy required enteral nutrition orders to include the product and administration method.
A resident with a GT, GERD, interstitial pulmonary disease, and dementia was observed receiving medications via the GT without the nurse confirming tube placement. The LVN stated she did not check GRV before administering the medications, and the RN and DON stated GT placement and residuals should be checked prior to medication administration, although the facility policy did not include GRV checking.
Inadequate G-tube care and enteral feeding documentation. A resident with CVA-related hemiplegia and dysphagia had orders for NPO status, continuous Jevity 1.5 via G-tube, water flushes, residual checks every shift, and oral care, but the record lacked an order for tube placement verification or shift site care. MAR/TAR review showed no consistent documentation of G-tube site care or residual checks, water flushes were not always documented as ordered, and feeding amounts were recorded in two places with inconsistent entries; nursing notes were also not present for every shift.
A resident with a g-tube, severe cognitive impairment, and dependence on staff for all nutrition and hydration did not receive continuous tube feeding at the ordered start time. The feeding pump was observed off while the resident was away from his room and remained off after he returned from the Day Center; an LVN later connected the feeding after changing the g-tube dressing. Staff stated the resident often returned after the ordered start time and was therefore not hooked up as ordered.
A resident with a G-tube was observed lying supine and below 30 degrees while enteral feeding was running. A CNA said the resident was lower than she should have been during the feeding and that the tube feeding should be turned off when repositioning is needed. An LVN later confirmed the resident should not be lying flat during feeding, paused the tube feeding, and said the resident needed assistance to be safely elevated; the DON stated the head should be elevated above 30 to 45 degrees and never flat during feeding.
Failure to Verify G-Tube Placement Before Medications and Water Administration: An LPN administered crushed meds and water through a resident’s PEG tube without routinely checking tube placement first. The resident had dysphagia, cognitive impairment, and received most calories and fluids via the feeding tube. The RN and DON also indicated uncertainty about whether placement checks were still required, and no provider order exempting the resident from placement verification was found, despite the facility policy requiring placement checks before tube feedings and meds.
Incomplete Enteral Feeding Order for Resident with G-Tube
Penalty
Summary
The facility failed to ensure that Resident #4, a male with a gastrostomy tube, unspecified protein-calorie malnutrition, and sequelae of protein-calorie malnutrition, received an enteral feeding order that included the formula strength and the specific administration method. Resident #4's significant change MDS reflected that he rarely or never made himself understood, sometimes understood others, and had long- and short-term memory problems. His care plan identified that he required tube feeding related to dysphagia and that tube feedings were to be administered per physician orders. The physician order summary dated 06/30/26 listed an active order for enteral feed four times daily via g-tube, but it omitted the Isosource strength and did not specify whether the feeding was to be given by bolus or pump. Hospice physician orders dated 06/19/26 were more specific and identified Isosource 1.5, four times daily. During interviews, the MDS Coordinator stated nursing staff had been administering Isosource 1.5 cal bolus feedings via g-tube. The LVN and DON both acknowledged the order was missing the strength and administration method, and the DON stated she could not recall whether she had added the administration method when updating the order. The facility policy on enteral nutrition stated complete orders include the enteral nutrition product and the administration method.
Failure to Verify GT Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate gastrostomy tube care for Resident 9 by not confirming GT placement before medication administration. Resident 9 was admitted and later readmitted with diagnoses including gastrostomy status, GERD, interstitial pulmonary disease, and dementia. The MDS dated 3/30/26 indicated the resident was severely impaired in cognitive skills for daily decision making, dependent for multiple activities of daily living, and had a feeding tube with a therapeutic diet. Physician orders dated 2/21/2026 directed continuous enteral feeding of Jevity 1.2 at 40 ml/hour for 20 hours via GT. During a concurrent observation and interview on 7/1/2026 at 9:51 AM, LVN 5 was observed preparing and administering medications to Resident 9 without confirming GT placement. LVN 5 stated she did not check the resident's gastric residual volume prior to giving medications, but should have done so to prevent aspiration. RN 2 and the DON later stated that GT placement and residuals should be checked prior to medication administration, and both acknowledged that checking GRV was not included in the facility policy even though the policy stated tube placement should be verified before administering fluids or medications.
Inadequate G-tube care and enteral feeding documentation
Penalty
Summary
Appropriate care and services were not provided for a resident receiving tube feedings. Resident 7 had diagnoses including cerebral infarction with right-sided hemiplegia and hemiparesis and dysphagia, and had orders for NPO status, continuous Jevity 1.5 enteral feeding via G-tube, water flushes, residual checks every shift, and oral care every six hours. The record also showed a care plan for tube feeding related to dysphagia and interventions for G-tube care every shift and local care to the G-tube site as ordered. Facility records did not show an order for gastrostomy tube placement verification before starting enteral feeding or for site care every shift. Review of the MARs/TARs from August 2025 through June 2026 did not reveal documentation that G-tube site care was provided every shift or that residual feeding was checked and the amount recorded. The ordered four-hour water flushes were not always documented as 150 mL, and there were two separate areas for staff to document the amount of feeding infused, with entries that did not consistently match the ordered amount or each other. Nursing progress notes sometimes stated that tube placement was confirmed by air auscultation, feeding was infusing without difficulty, no residual was noted, and the G-tube site had no signs or symptoms of infection, but these notes were not present for every shift of every day.
Delayed G-tube Feeding Administration
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received enteral feeding at the physician-ordered time. Resident #42, a male with athetoid cerebral palsy, muscle wasting and atrophy, and gastrostomy status, was assessed as severely cognitively impaired and dependent on staff for all nourishment and hydration. His care plan and order summary directed Jevity 1.5 at 85 mL/hr with water at 68 mL/hr via pump from 3:00 PM to 6:00 AM, and he was also documented as NPO and at risk for dehydration related to PEG feedings. On observation, the resident’s feeding pump was found next to the bed and turned off at 3:07 PM while he was not in his room. At 4:16 PM, after he returned from the Day Center, the pump was still off. At 4:42 PM, an LVN was observed changing the g-tube dressing and then hooking the resident up to his feeding. Staff interviews indicated the resident often returned from the Day Center after the ordered start time, and the DON and ADM stated he was not connected at 3:00 PM because of his late return. The ADM stated the resident was not receiving the full 15 hours of formula and hydration as ordered, and the DON stated staff were trained to follow physician orders for g-tube nutrition.
Resident with G-tube was fed while lying flat
Penalty
Summary
A deficiency was cited after a resident with a G-tube was observed lying in bed supine and halfway down the bed while enteral feeding was running. The resident’s head was against the back rest of the bed with the neck bent forward, and the resident was positioned at less than 30 degrees during the feeding. A CNA stated the resident was lying lower than she should have been while the tube feeding was running and said the feeding should be turned off when the resident needs repositioning. During the same observation, an LVN assessed the resident and stated the resident should not be lying supine while enteral feeding was being delivered. The LVN paused the tube feeding and said additional assistance was needed to safely elevate the resident from the supine position, adding that the feeding should not be on when the resident was lying flat because it can lead to aspiration and choking. The DON later stated the resident’s head should be elevated above 30 to 45 degrees to prevent aspiration and that the resident should never be lying flat. The facility policy titled Gastrostomy Tube Care and Management stated that before every feeding the tube position should be verified and, if feeding is continuous, the position should be checked every shift and as needed.
Failure to Verify G-Tube Placement Before Medications and Water Administration
Penalty
Summary
The facility failed to follow its policy for verifying gastrostomy tube placement before administering medications and water to a resident with a PEG tube. R6 was admitted in February 2026 with diagnoses including oropharyngeal dysphagia, severe physical deconditioning, and cognitive impairment. Her accepted quarterly MDS assessment identified moderate cognitive impairment, dependence on staff for all ADLs, impairment of upper and lower extremities, wheelchair use, and receipt of 51% or more of total calories and 501 cc or more of fluids daily through the feeding tube. R6’s care plan identified her as at risk for impaired nutritional status related to G-tube feedings and directed staff to keep her upright during and after feedings, flush the tube with water before and after feedings or medication administration, and notify the provider for tube dislodgement or patency concerns. Her physician orders included Isosource tube feeding and scheduled free water flushes through the PEG tube. During observation, an LPN prepared crushed medications and administered them through the G-tube without routinely checking placement first. He elevated the head of the bed, inserted a syringe into the tube, opened the stopcock to let air escape, and administered water and medications by gravity. During interview, the LPN stated he did not routinely check G-tube placement before giving medications or water and believed it was not needed because the tube had previously been verified by x-ray when changed. He also was unsure about the small amount of liquid noted at the tube site during administration. The RN stated she did not think placement still needed to be checked and would need to review the policy, while the DON stated she thought there was a provider order exempting R6 from placement checks, but no such order was found. The facility policy required checking proper placement of the G-tube prior to medication administration and documenting verification of tube placement.
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