Improper Replacement of Dislodged Jejunostomy Tube by Nursing Staff
Penalty
Summary
A deficiency occurred when a nurse failed to provide appropriate care for a resident with a recently placed jejunostomy tube (j-tube) after it became dislodged. The resident, who had a history of stroke, global aphasia, dysphagia, and was fully dependent on tube feeding, was found without his j-tube in place. The nurse, who was an agency nurse unfamiliar with the specific type of tube, did not recognize the need for hospital treatment and instead inserted an indwelling urinary catheter tube into the j-tube site without a physician's order. This action was taken after consultation with the Wound Nurse, who advised replacing the tube with a similar-sized enteral tube or urinary catheter, but also instructed to call the provider for an order. The nurse did not obtain a physician's order before proceeding. The replacement tube became dislodged again within a short period, and the resident was subsequently sent to the hospital for reinsertion. Interviews revealed that the nurse was unaware the tube was a j-tube rather than a gastrostomy tube and stated she would have sent the resident to the hospital if she had known. The Wound Nurse and DON both confirmed that facility policy did not permit nurses to replace j-tubes in the facility, only gastrostomy tubes with a physician's order. The DON and Medical Director emphasized that j-tubes require surgical or radiological placement and that the site was not mature, increasing the risk of complications. The nurse did not complete documentation related to the incident, and the DON had to document the event after being notified. Additional interviews with staff and the responsible party confirmed that the tube was found on the floor, and the resident was bleeding from the site. The responsible party found the resident attempting to stop the bleeding and called for assistance. The resident was transferred to the hospital, where multiple attempts were made to replace the tube, ultimately requiring surgical intervention. The incident was identified as affecting one resident reviewed for feeding tubes, and the facility's failure to follow proper procedures for j-tube dislodgement led to the deficiency.
Removal Plan
- The Director of Nursing, Assistant Director of Nursing, and Unit Managers will provide education to Licensed Nurses on Enteral Feeding Tube(s) Policy, including what to do if a j-tube becomes dislodged, physician notification, not to attempt reinsertion of the j-tube, and sending the resident to the hospital for surgical reinsertion.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence, vacation, agency staff or PRN staff will be re-educated prior to returning to duty by the DON or ADON.
- New hires and Agency Nurses will be educated by the Director of Nursing or Assistant Director of Nursing during the orientation process.
- The DON or ADON will review all new admissions in the Clinical Morning Meeting to determine if any admissions have a j-tube present and ensure all Licensed Nursing staff are made aware of the presence of a j-tube and the process for physician notification and treatment if a j-tube becomes dislodged.
- Licensed nurses will be made aware of residents that are admitted with a j-tube via the Admission Notification Form that is provided by the Admission Director for all pending admissions.
- Admission Notification Form will be delivered to the admitting nurse with the hospital discharge summary by the Admission Director prior to resident arrival.