Failure to Prevent and Investigate Repeated Gastrostomy Tube Dislodgement
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received appropriate care and services to prevent complications related to repeated dislodgement of the GT. The resident experienced multiple incidents of GT dislodgement on at least seven separate occasions, each requiring medical intervention and replacement of the tube. Despite these repeated events, the facility did not conduct assessments or document investigations into the possible causes of the dislodgements, except for one incident. There was also no evidence of updated or modified interventions to prevent further occurrences, and no interdisciplinary team (IDT) meetings were held to address the frequent GT dislodgement. Staff interviews revealed that the primary intervention implemented was the use of an abdominal binder to prevent the resident from pulling at the GT, along with a sign instructing staff to keep the resident's right arm outside the sheets. However, staff also reported that the GT had been pulled out by staff during repositioning and that there were lapses in supervision, such as leaving the resident alone without the abdominal binder during shower preparation. Additionally, the shower team was not consistently informed about high-risk residents prior to showers. The facility's lack of investigation, documentation, and updated interventions contributed to the ongoing issue of GT dislodgement for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a feeding tube, severe cognitive impairment, quadriplegia, and persistent vegetative state was observed receiving g-tube feeding at 55 mL/hr even though the physician order specified Isosource 1.5 at 85 mL/hr for 22 hours. An LVN confirmed the incorrect pump rate and stated he was unsure why it was set that way, while the DON and ADM stated staff were expected to verify orders and pump settings and that nursing was responsible for tube feeding administration.
A resident with a G-tube, CVA, dysphagia, and severe cognitive impairment was observed receiving incontinent care with the HOB flattened while tube feeding continued to infuse. Two CNAs did not call the nurse to stop the pump before care, and the resident remained flat for 36 minutes while appearing uncomfortable. Interviews confirmed staff knew the pump should be stopped and that only nurses handle the tube and pump.
Two residents with feeding tubes had enteral nutrition documented inconsistently with provider orders. For one resident, staff recorded pump on/off times but not the total amount infused; for another resident, nurses only initialed shifts without documenting actual start/stop times or fluid amounts. An LPN, resident care manager, and DON acknowledged the documentation did not meet expectations.
A resident with severe cognitive impairment and tube feeding orders had formula and a water flush bag that were not dated or labeled. The care plan addressed tube feeding, aspiration monitoring, and keeping the HOB elevated, and an RN stated she checks placement, primes the pump, and verifies the formula is not expired, labeled, and dated. Facility policy required checking the enteral nutrition label against the order, including the resident name, formula type, preparation date and time, and rate of administration.
An LVN failed to verify GT placement and check GRV before administering medications to a resident with dysphagia, a GT, and severely impaired cognitive skills. The resident’s orders required GT placement/patency checks and residual checks every shift, and the facility policy required tube placement verification and residual checks before medication administration.
Improper Head-of-Bed Positioning During GT Feeding: A resident receiving GT feeding was observed lying in bed with the HOB at 20 degrees while the feeding was actively infusing, despite the care plan and facility P&P directing HOB elevation to 30 to 45 degrees or upright positioning during and after tube feeding. An LVN confirmed the resident should have been at 45 degrees and verified the lower HOB setting during the feeding; the Administrator and DON acknowledged the findings.
Incorrect Enteral Feeding Rate
Penalty
Summary
The facility failed to follow the physician’s enteral feeding order for Resident #6, a male admitted with acute and chronic respiratory failure, quadriplegia, and persistent vegetative state. His quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment, and documented that he had a feeding tube and received 51% or more of his total calories through tube feeding. His care plan identified a risk for malnutrition related to BMI and directed staff to administer enteral feedings as ordered. The physician order in the record directed Isosource 1.5 at 85 mL/hr for 22 hours. Observations on 06/09/2026 and 06/10/2026 showed the resident receiving g-tube feeding with the pump rate displayed at 55 mL/hr instead of the ordered 85 mL/hr. During interview, an LVN confirmed the pump was set at 55 mL/hr and stated he was not sure why it was set that way and was not aware of any order changes. He also stated he was responsible for setting the correct rate and monitoring the pump during the shift. The DON and ADM stated staff were expected to check orders and rates and ensure they matched, and the facility policy stated nursing was responsible for tube feeding administration and correcting problems with tube feeding.
Feeding Tube Left Infusing While Resident Was Flat During Care
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a feeding tube when CNA G and CNA J lowered the head of the bed to a flat position while the resident’s enteral feeding continued to infuse. The resident, a male with a history of CVA, dysphagia, severe cognitive impairment, unclear speech, and dependence on staff for ADLs and mobility, had physician orders for NPO status and continuous tube feeding at 75 mL/hr with the head of bed elevated 30-45 degrees. During observed incontinent care, the CNAs did not contact the nurse to stop the tube feeding before flattening the bed. The feeding pump continued to infuse while the resident remained flat for 36 minutes as staff provided care. During this time, the resident grunted, patted the top of his head, grasped the handrail, groaned, and appeared uncomfortable while additional cleaning was needed after he had a bowel movement. In interviews, CNA J stated she should have called the nurse to stop the pump but forgot, and acknowledged prior training that the resident could choke if his head was lowered while feeding was running. LVN C stated the CNAs normally call her to stop the pump and that the pump must be off when the resident is flat or he could aspirate. Other CNAs and the DON stated they had been trained that only nurses handle the G-tube and pump and that the resident could potentially aspirate if the head of bed was flat while tube feeding was infusing. The facility policy also stated staff caring for residents with feeding tubes are trained on complications of enteral nutrition and that aspiration risk may be affected by improper positioning during feeding.
Tube Feeding Administration and Documentation Deficiencies
Penalty
Summary
Enteral nutrition was not administered and documented in accordance with provider orders for two residents who had feeding tubes. Resident 9 was admitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, dysphagia, and aphasia, and was assessed to require nutrition through a feeding tube. The care plan identified the resident as at nutritional risk. A provider order dated 03/05/2026 directed Jevity 1.5 to be given continuously via pump at 97 milliliters per hour for 15 hours each day, from 8:00 PM to 11:00 AM. Review of the May 2026 MAR showed staff documented only the times the pump was turned on and off, but did not document the total amount of enteral feeding infused. Staff M stated nursing staff were not documenting the total received on the MAR or in a progress note, and Staff B stated the MAR should have included supplemental documentation for the amount of nutrition received daily. Resident 4 was admitted with diagnoses including diabetes, dysphagia, and artificial tube feeding, and could communicate needs. The resident stated the tube feeding was turned off at 7:00 AM and restarted at 9:00 AM, while the MAR order directed Osmolyte at 70 milliliters per hour for 22 hours, off at 5:00 AM and restarted at 7:00 AM. The MAR showed nurses initialed day and night shifts without documenting the actual times or fluid amount given. Staff O stated the tube feeding should have been documented with specific start and stop times and the amount given, and Staff B stated the documentation did not meet expectations.
Tube Feeding Formula and Flush Bag Not Dated or Labeled
Penalty
Summary
The facility failed to provide appropriate tube feeding management for one resident, R10, who was admitted with diagnoses of Alzheimer's disease, dementia, and atrial fibrillation. R10's quarterly MDS showed a BIMS score of 0 out of 15, indicating severely impaired cognition. The care plan identified that R10 received nutritional formula via tube feeding and included interventions to keep the head of bed at least 30 degrees and to monitor for aspiration and nausea/vomiting. An observation revealed that R10's tube feeding formula and water flush bag were not dated and labeled. During an interview, an RN stated that her process with tube feeding included disconnecting R10 from the pump, checking placement when reconnecting, priming the pump, ensuring the head of bed was at 40 degrees, and making sure the formula was not expired and was labeled with the resident's name and dated. The facility policy for enteral feedings stated that the enteral nutrition label should be checked against the order before administration, including the resident name, identification, room number, type of formula, date and time formula was prepared, and rate of administration.
Failure to Verify GT Placement and Residual Before Medication Administration
Penalty
Summary
Licensed Vocational Nurse 1 failed to verify the placement of Resident 20’s gastrostomy tube and failed to check the gastric residual volume before administering medications through the tube. During medication administration observation, LVN 1 did not verify or assess GT placement and did not check the GRV prior to giving medications. In interview, LVN 1 stated he forgot to check the GT placement and gastric residual before administering the medications and acknowledged that he should have verified both before use. Resident 20 was admitted and later readmitted to the facility with diagnoses including hemiplegia affecting the right dominant side, dysphagia, and gastrostomy. The resident’s MDS indicated severely impaired cognitive skills and need for substantial to maximal assistance with several activities of daily living, and the H&P stated the resident did not have the capacity to understand and make decisions. The order summary required GT placement and patency checks every shift and residual checks every shift, and the facility’s policy for medication administration via enteral tube required verification of tube placement and checking residual amounts before administering medications.
Improper Head-of-Bed Positioning During GT Feeding
Penalty
Summary
The facility failed to provide necessary GT care and services for one of four sampled residents, Resident 1. The deficiency involved enteral feeding administration and positioning. The facility’s policy for administration of enteral nutrition, dated 1/2026, directed staff to position the resident with the head of the bed elevated at least 30 degrees or upright in a chair to prevent aspiration. Resident 1’s care plan included interventions to elevate the head of the bed 30 to 45 degrees during tube feeding and to maintain that elevation for 30 to 40 minutes after feeding stopped, and another care plan problem for GI bleeding and GERD directed that the resident be positioned upright while tube feeding was running and for 30 to 45 minutes afterward. During observations on 5/29/26, Resident 1 was seen lying in bed with the head of the bed at 20 degrees at 0929 hours and again at 1025 hours. At 1306 hours, LVN 1 stated the head of the bed should be at 45 degrees because Resident 1 was receiving GT feeding, then verified the head of the bed was still at 20 degrees while the GT feeding was actively infusing. At 1700 hours, the Administrator and DON were interviewed and acknowledged the findings.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.