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F0726
E

Lack of Competency in Tube Feeding Administration Delays Resident Care

Portland, Oregon Survey Completed on 11-20-2025

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

Licensed nursing staff failed to demonstrate the necessary competencies to care for a resident with a feeding tube. A resident with a history of Gastroesophageal Reflux Disease (GERD) and choledochoduodenal fistula was admitted with physician orders for scheduled tube feedings. On the scheduled day, an LPN was observed to have difficulty identifying and managing the resident's feeding tube due to a missing connector. The LPN left the room to seek assistance after expressing uncertainty about the correct connection method. The Interim Director of Nursing Services (DNS) also entered the room but was similarly unsure about the appropriate procedure for the feeding tube. Multiple staff members, including the MDS Coordinator, were involved in attempts to resolve the issue, but compatible connectors were not immediately available. As a result, the resident's tube feeding was delayed by two and a half hours. Staff interviews and record reviews revealed that the LPN had not received adequate training in tube feeding administration and required further orientation, as indicated by a skills checklist completed after the incident.

An unhandled error has occurred. Reload 🗙