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F0693
D

Failure to Verify Feeding Tube Placement Using Approved Method

Rockford, Illinois Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to verify the placement of a gastric feeding tube using an approved method prior to administering medications and a bolus feeding to a resident. The resident in question had multiple diagnoses, including colon cancer, stroke, high blood pressure, and hemiplegia, and was dependent on staff for all care, including tube feeding. During observation, a registered nurse checked tube placement by injecting air into the tube and listening with a stethoscope, a method that is no longer considered best practice. The nurse then proceeded to administer medications and feeding through the tube. Interviews with nursing staff revealed uncertainty regarding the facility's policy for verifying tube placement, with both the nurse involved and another RN unable to locate a clear policy. The Director of Nursing acknowledged that the current policy was vague and in the process of being updated, and confirmed that air insufflation is not the best practice. Facility guidelines and care plans required verification of tube placement before administering feedings or medications but did not specify the method to be used.

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