Improper Feeding Tube Replacement Leads to Immediate Jeopardy
Summary
The facility failed to replace a feeding tube in accordance with professional standards of practice for a resident, resulting in Immediate Jeopardy. A registered nurse (RN) inserted a urinary catheter with a 30 cc balloon into the gastrostomy site of a resident, which led to the resident experiencing blood-tinged vomiting, low oxygen saturation, and a decreased heart rate. The resident was transferred to the hospital, where an x-ray confirmed that the urinary catheter balloon was inflated in the resident's esophagus, leading to aspiration pneumonia and the resident being placed on comfort care measures. The resident, who had a primary diagnosis of cerebral palsy and was dependent on staff for all activities of daily living, had been using a catheter as a feeding tube for many years. The RN who inserted the catheter did not receive training or competency evaluations for changing a gastrostomy tube or inserting a urinary catheter as a feeding tube. The facility's Director of Nursing (DON) acknowledged that no training or competency evaluations had been completed for the nursing staff regarding these procedures. Additionally, the facility did not use securement devices to prevent dislodgment or migration of feeding tubes. The facility's policies did not include x-ray verification for placement after inserting an enteral tube, nor did they provide adequate guidance for ensuring proper tube placement. The DON confirmed that the medical director was not aware that the nurses had not been trained or competency-evaluated on changing feeding tubes or inserting catheters in lieu of feeding tubes. The facility's failure to adhere to professional standards of practice and provide adequate training and policies resulted in significant harm to the resident.
Removal Plan
- Resident R1 no longer has a foley catheter as a G-tube. The resident returned from the hospital with MIC-KEY low-profile tube in place.
- The physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube.
- For current and new residents, all residents receiving tube feeding were assessed for the presence of a G-tube. Only one was identified. The physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube.
- The physician ordered X-ray verification of the placement of current feeding tube to set a baseline for measuring.
- The facility's policies Gastric Tube Feeding and Policy and Procedure: Tube Feeding has been amended that the resident will be sent to the ED for replacement and measurements will be done to verify placement prior to medication administration, water flush, or start of formula. Also to notify the physician for any abnormalities including dislodging.
- The facility policy Insertion on indwelling catheter for gastric feeding has been removed.
- All nursing staff working day shift have been educated on the policy changes and competency tested for measuring.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a G-tube and diagnoses including stroke and pneumonitis had tube feeding ordered at 60 ml/hr, and the care plan identified increased nutritional risk related to gastric tube use. Staff observed the tube feeding bag hanging with an additional water bag, and both bags were not labeled with the resident’s name, formula, rate, date, or time hung; an RN and an LPN confirmed the unlabeled setup.
A resident with quadriplegia, dysphagia, and severe cognitive impairment had a G-tube used for meds, water flushes, and enteral nutrition. An LPN administered water, meds, and formula through the tube without checking placement or residual first, and the resident's care plan and MD orders did not include instructions to verify tube placement before use.
A resident with a GT, dysphagia, Parkinson's disease, and failure to thrive was observed lying flat in bed while receiving enteral feeding and water via pump, despite orders and care plan directions to keep the HOB elevated during feeding. The water bag connected to the pump was also not labeled with the resident's name, date, and time, and an LPN confirmed both the unlabeled bag and the resident's flat positioning during the feeding.
A resident with dysphagia, severe cognitive impairment, and dependence on staff for ADLs received nocturnal Jevity 1.5 via feeding tube, but the bottle was not dated or timed when opened and the tubing was undated. During observation, the feeding was running on a pump while the resident rested in bed with the HOB elevated, and an LPN and the DON confirmed the dating and timing were missing.
A resident who depended on PEG tube feeding was ordered Jevity 1.5 at 60 mL/hr for 22 hours daily with free-water flushes, but was observed disconnected from the feeding with the pump turned off and about 1,300 mL of formula still hanging at the bedside. An LPN confirmed she had not connected the feeding and said she forgot to do so, and the DON later confirmed the enteral feeding had not been connected as ordered.
A resident with dysphagia, protein-calorie malnutrition, and dementia had a GT feeding ordered to run 20 hours daily via pump. During observation, the pump was found inactive, paused, and alarming with feeding still remaining in the bottle, and an LVN said she was unaware of the alarm or why the pump was paused. The DON stated tube feedings may be paused for care or meds but should be restarted as soon as possible so the resident receives the full ordered dose.
Unlabeled Tube Feeding Bags
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an enteral feeding tube. Resident R181 was admitted with diagnoses including pneumonitis, stroke, and hemiplegia, and had a physician order for Isosource 1.5 tube feeding at 60 ml/hr. The resident’s care plan identified increased nutritional risk related to gastric tube use and included enteral feeding/supplements to support normal lab levels. During observation, Resident R181’s tube feeding bag was hanging on a pole with another bag of water. On both observations, the bags were not labeled with the resident’s name, the formula, the rate, the date, or the time it was hung; one observation also noted the bags were not labeled with the resident’s name, formula, or rate. RN E4 and LPN E17 both confirmed the unlabeled tube feeding setup and the presence of the additional water bag on the pole.
Feeding Tube Placement Not Verified Before Use
Penalty
Summary
The facility failed to ensure a resident's G-tube was monitored for placement before medications and enteral nutrition were administered. The resident had diagnoses of quadriplegia and dysphagia, was severely cognitively impaired, and was dependent on staff for all ADLs except eating because of the feeding tube. The resident's feeding tube care assessment documented that staff were to provide enteral feedings and keep the head of the bed elevated during feedings, and the care plan directed staff to provide tube feeding five times daily with 60 mL water flushes before and after each feeding. However, the care plan and physician orders lacked instructions to check feeding tube placement before use. On observation, a licensed nurse assisted the resident to his room, performed hand hygiene, applied gloves and a gown, connected the feeding tube to a syringe, and administered 60 mL of water, medications, and one carton of Isosource 1.5 through the tube without checking placement or residual first. The nurse later stated she forgot to check placement when giving the water and enteral feeding, though she said she normally did and had checked residual earlier that morning. An administrative nurse stated she expected the nurse to check the measurement of the feeding tube before use to verify placement and believed that direction was on the resident's orders, but the orders did not include placement or residual checks.
GT Feeding Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide necessary GT care and services for Resident 9, who was admitted with diagnoses including encounter for attention to gastrotomy and oral phase dysphagia and whose history included failure to thrive and Parkinson's disease. The resident's physician orders directed that the head of bed be elevated at least 30 degrees during feeding and for one hour after feeding, and the care plan also directed head-of-bed elevation during enteral feeding. During observation on 7/27/26, Resident 9 was seen lying flat in bed with the head resting on one pillow while receiving enteral feeding and water through a feeding pump. The observation also showed that the water bag connected to the feeding pump was not labeled with the date and time it was connected to Resident 9. CNA 2 stated the resident had been lying flat in bed since the start of the shift, and LVN 4 confirmed the resident was lying flat while receiving the feeding and water. LVN 4 also verified that the water bag was not labeled with the resident's name, date, and time when it was changed, and stated the head of bed should be elevated at least 40 degrees during feeding.
Tube Feeding Not Dated or Timed
Penalty
Summary
The facility failed to ensure a tube feeding bottle was dated and timed when opened for one resident receiving enteral nutrition. The resident had diagnoses including hemiplegia/hemiparesis, dysphagia, hyperlipidemia, aphasia, and hypertension. The quarterly MDS identified the resident as having unclear speech, severe cognitive impairment, dependence on staff for activities of daily living, and receipt of tube feedings. The resident had physician orders for nocturnal Jevity 1.5 feedings at 83 ml per hour from 7:00 p.m. to 7:00 a.m. During an observation, the resident was resting in bed with the head of the bed at approximately 30 degrees while Jevity 1.5 was running at 83 ml per hour on a pump. The bottle had no open date or time, and the tubing was not dated. An LPN verified that the bottle was not dated or timed when opened and that the tubing was undated, stating it should be dated and timed to ensure the tube feeding does not hang longer than it should. The DON stated it was her expectation that staff would date, time, and initial the tube feeding bottle and tubing.
Enteral Feeding Not Administered as Ordered
Penalty
Summary
R6, a resident with anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, tracheostomy status, epilepsy, myoclonus, and morbid obesity, was admitted with enteral nutrition as the sole source of nutrition through a PEG tube. The resident’s physician ordered Jevity 1.5 at 60 mL per hour for 22 hours daily, starting at 2:00 PM and stopping at 12:00 PM the following day, with free-water flushes at 50 mL per hour for 22 hours. The care plan addressed enteral feeding, hydration, aspiration precautions, tube dysfunction monitoring, and gastrostomy site care, and the RD documented continuation of the prescribed regimen. During observation, R6 was found disconnected from the enteral feeding with the pump turned off, and a bottle of Jevity 1.5 remained hanging at the bedside with approximately 1,300 mL still in it. The feeding was observed again later the same day still not connected, with the pump off and the same amount of formula remaining, even though a new 22-hour feeding cycle should have been underway. An LPN assigned to R6 confirmed she had not connected the feeding, was unsure who had disconnected it, and stated she forgot to connect it because there were a lot of things going on. The DON was notified and later confirmed the enteral feeding had not been connected and that this was an error.
Feeding Tube Pump Left Paused and Alarming
Penalty
Summary
Resident 15, who had diagnoses including dysphagia, protein-calorie malnutrition, and dementia, was admitted and later readmitted to the facility and was assessed as having severely impaired cognitive skills, requiring substantial to total assistance with activities of daily living, and receiving 51% or more of calories from a feeding tube. A physician order dated 5/7/2026 directed Osmolite 1.5 at 45 cc per hour for 20 hours via pump through the G tube, providing 900 ml/1350 kcals/56 g protein from 2 PM to 10 AM. During observation on 7/28/2026, the resident's enteral feeding pump was alarming and displayed that the pump was inactive and had been idle for 10 minutes, with the feeding bottle dated and timed for the prior day and about 300 cc remaining. Sixteen minutes later, the pump was still paused and alarming, and the LVN stated she was not aware the pump was alarming or why it was paused. The LVN stated that if the feeding stopped at 10 AM or even an hour later, the resident would not receive the full ordered dose of enteral feeding. The DON stated staff may pause tube feedings for care or medication administration but should restart them as soon as possible, and that failure to restart right away could result in inadequate caloric intake.
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